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SP - Supervisor Agreement Form


Please complete this form to verify your participation in the service practicum program. Please complete one form for each CBC student you are supervising. For more info please contact Christy Brown (Christy.Brown@columbiabc.edu)

Required fields are marked with an asterisk (*)
 
Student's Name *
 
Supervisor's Name *
 
Supervisor's Position *
 
Organization Name *
 
Supervisor (Organization) Address
 
City
 
Postal Code/Zip
 
Province/State
 
Supervisor Email address *
 
Supervisor Phone Number *
() -
 
Student's Job Title *
 
Student's Job Description (please fill in if not already registered with CBC)
 
 
Please choose the best descriptor: *
This placement IS registered with CBC
This placement IS already registered with CBC, and I need more students; please continue to post this information for other students
This placement is NOT registered with CBC, but the student has previously been involved with us and we would like him/her to continue
This placement is NOT registered with CBC, but the student has expressed interest in serving here
This placement is NOT registered with CBC but we have more positions available (please fill out an application form - contact the Service Learning Dept for more info)
 
Other information or comments
 

I have read the CBC Service Practicum Supervisor Manual

*
  Yes No
 
Please send me a copy of the Supervisor Manual *
  Yes No
 

I understand that I will need to provide an evaluation and verify attendance for the above student.

I also understand that I must connect with the above student to challenge and encourage the student at least twice each semester.

I agree to do my best to fulfill those requirements as I supervise my student in their Service Practicum placement.

*
  Yes No
A copy of this form will be sent to your email address - if you do not receive a copy, please contact Christy Brown (Christy.Brown@columbiabc.edu)
Enter the letters you see in the image below:



Thank you very much! We look forward to working with you.