Contact Form

Contact Form

The Contact Form should be submitted as soon as you have confirmed your Practicum position. The Contact form should include all of the following information:

Student Information:

Name: _____________________________________________________________

Address: ____________________________________________________________

City: ____________________________  State: _________  Zip: ________________

Work Phone Number: (       ) _______________________  Home Phone Number: (     ) ___________________________

e-mail:  _____________________________________________________________

Job Title and brief job description: __________________________________________________________________

_______________________________________________________________________________________________

Student Practicum Goals: Please identify 3 goals you hope to achieve during your Practicum experience.

1) _______________________________________________________________________________________

2) _______________________________________________________________________________________

3) _______________________________________________________________________________________

Agency Information:

Agency name: ________________________________________________________

Supervisor name: _________________________________________________________

Address: ____________________________________________________________

City: ____________________________  State: _________  Zip: ________________

Phone number: (       ) _______________________________

Supervisor's e-mail: ________________________________________________________

Total Hours to be worked: ________________

Send to: Dr. Charles Hammersley:

E-mail to: charles.hammersley@nau.edu

Fax (928) 523-2275

Mail to: Dr. Charles Hammersley, Northern Arizona University, Parks and Recreation Program,

70 McConnell Drive, Room 201, PO Box 15016, Flagstaff, AZ  86011-5016

[Class]

Copyright 2000 Northern Arizona University, ALL RIGHTS RESERVED