APPLICATION
FOR PRACTICUM PLACEMENT
OKLAHOMA
STATE UNIVERSITY – OKLAHOMA CITY
Alcohol
and Substance Abuse Counseling
Date:______________________________Semester:
__________________________
Name:________________________________________________________________
Mailing
Address:________________________________________________________
_________________________________________________________
E-Mail
Address:_________________________________________________________
Home
Phone:__________________________ Cell Phone:______________________
Please
list your top three practicum placements in order from most preferred:
1)____________________________________________________________________
2)____________________________________________________________________
3)____________________________________________________________________
List
any previous RELATED work experience (paid or volunteer):
-_____________________________________________________________________
-_____________________________________________________________________
-_____________________________________________________________________
Describe
your career goal(s):
-_____________________________________________________________________
______________________________________________________________________
In
case of an Emergency, state person to be notified and their phone number:
-_____________________________________________________________________
______________________________________________________________________
In
the space below, briefly describe your strengths and challenges you feel you
posses that relate to your practicum placement:
Describe
what you hope to learn through your placement:
(All
items in the previous pages should be filled-in for this application to be
considered complete.)
Student
Signature:_______________________________________________________
Date:_________________________________________________________________
Revised
June 2010