Student’s Name: ________________________________ ID #:___________________

Program of Study: _________________________________________________

Year of Study: ____________________________________________________

Location of Community Practicum: ____________________________________

Hours per Week: __________________________________________________

Start Date: _______/____/_________ End Date: _______/____/_______

DD/MM/YYYY DD/MM/YYYY

Description of Community Practicum:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Name of Supervisor: _______________________________________________

Telephone number of Supervisor: _____________________________________

Student’s Signature: ________________________________________________

Community Practicum Form

Office Use Only

Date Received:_________________ CP #:______________________

Input Date:____________________ Term Code:_________________