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SP - Student Placement Application Form


Please complete the following form, which will be submitted to the Service Learning Department for approval.

Required fields are marked with an asterisk (*)
 
Student Name *
 
CBC Mailbox # *
 
Email Address *
 
Phone Number (that we can reach you at if necessary!) *
  () -
 
Personal information (please check all that apply, these help us know your needs) *
  Resident Student
Commuter Student
Married
Have young children
work part time
work full time
live outside the Abbotsford area
full time student at CBC
part time student at CBC
attending CBC and another school
 
I am registered in Service Practicum (choose your course) *
  SP I (ME151)
SP II (ME152)
SP III (ME251)
SP IV (ME252)
 
My CBC program or major is *
 
Please Choose 1 *
I am applying to use a placement I am already involved in
I am applying to use a placement I found on the SP website
I am applying to use a placement I found at the service fair
I am applying to use a placement that I have not been involved in yet, but have found on my own
 
Other (please specify)
 
Practicum Type (eg. children, youth, worship) *
 
 
Day of week and time *
 
Organization Name *
 
Organization Address *
 
City *
 
Postal Code/Zip *
 
Phone Number (main contact) *
() -
 
Supervisor's Name *
 
Email Address (main contact)
 
***SP III and IV students only*** How does this placement relate to my major (if required for program)
 
 
For SP III and IV students only; Have you received verbal approval from your program director?
  Yes No
 
Information release to supervisor (please choose one) *
  I will allow the service practicum office to provide my phone number and email address to my supervisor
Please do not share my phone number or email address with my supervisor
 
Identity information release: (please choose one) *
  I give permission for the SP office to use my photo and name in the service practicum class, forms, manual and other SP publications
Please do not use my photos or name for service practicum
 
I understand that by typing my name here, I agree to the above two choices *
 
 
I understand that to received credits for my service, I must complete all the requirements as outlined in the SP handbook and syllabus. I am aware of those requirements and my responsibility to the Service Learning Department and program. I also commit to praying for my service placement and supervisor. *
  I agree
 
Date completed *
 
Comments
A copy of this form will be sent to your email address
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Thanks for filling this out! Blessings as you serve...