PRACTICUM IN EARLY CHILDHOOD PROGRAM ADMINISTRATION APPLICATION (HSL 4225)

We require you to provide the needed information for your practicum approval request.

Student Name *
E Number *
Enter your EIU/Panther Email, or your request will not be processed. *
Phone Number (NO SPACES OR DASHES) *
When did/will you complete HSL 4220 with a C or higher? *
Semester you wish to complete your Practicum:
Practicum Site Name *
Practicum Site Address Practicum Site Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Practicum Site Supervisor (If you do not know who will supervise you when on site, use the name of your current contact person) *
Practicum Site Supervisor Email *
Practicum Site Web Site *
Practicum Site Phone Number (NO SPACES OR DASHES) *
Describe your responsibilities for the practicum experience and how they relate to your area of study. Be specific. Make sure your work is proof-read and free of errors. This should be approximately 200-300 words *
Describe three to four objectives specific to your practicum experience (what you hope to gain from the practicum). This should be approximately 200-300 words in a bullet or listed format. *
Please confirm the following: *

Please confirm the following: I have discussed everything listed here with the practicum site supervisor. My site supervisor has at least a Bachelors degree and is qualified to supervise at this site. I have received notice from the site supervisor listed that I will be approved to do my practicum at this site. I am not employed by the agency/organization/institution that is my proposed practicum site. The site supervisor listed is not my relative or friend.
List any other potential conflicts of interest at this site, and provide rationale as to why this conflict of interest will not affect your internship.
For example, if a family member or friend works at the facility, you need to list it as a conflict of interest. If you do not provide solid rationale as to how this will not affect your work as an intern, your internship application will be denied, and you will need to find another site. *