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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