PRACTICUM IN EARLY CHILDHOOD PROGRAM ADMINISTRATION APPLICATION (HSL 4225)
PRACTICUM IN EARLY CHILDHOOD PROGRAM ADMINISTRATION APPLICATION (HSL 4225)
We require you to provide the needed information for your practicum approval request.
Student Name
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E Number
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Enter your EIU/Panther Email, or your request will not be processed.
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Phone Number (NO SPACES OR DASHES)
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When did/will you complete HSL 4220 with a C or higher?
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Semester you wish to complete your Practicum:
Fall
Spring
Summer
Practicum Site Name
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Practicum Site Address
Practicum Site Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
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Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Gibraltar
Greece
Grenada
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Practicum Site Supervisor (If you do not know who will supervise you when on site, use the name of your current contact person)
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Practicum Site Supervisor Email
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Practicum Site Web Site
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Practicum Site Phone Number (NO SPACES OR DASHES)
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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
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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.
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Please confirm the following:
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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.
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