Practicum Application

Please select the practicum track and semester you are applying for:

Track*

Addiction Treatment Services
Prevention Service

Semester*

Spring
Fall

Year*

Student Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Enter Email Confirm Email

Primary Phone*

Major*

Anticipated Graduation Date*

Employment Information

Employed*

Yes
No

Place of Employment*

Approximate Number of Hours Worked Weekly*

Job Description*

Is your place of employment flexible to your school schedule?*

Yes
No

Additional Comments Regarding Employment:

Preferred Setting, Population and/or Location for Placement

Population*

(i.e., Adolescents, Adults, Seniors)

Setting*

(i.e., Methadone Clinic, Criminal Justice, Hospital)

Preferred Site Location if Known:

(i.e., Quest, Alta-Vista, Children’s Cabinet)

Courses Completed

Have you completed CAS 354?*

Yes
No

CAS 354 Instructor*

When do you plan to complete CAS 354?*

Have you completed CAS 355?*

Yes
No

CAS 355 Instructor*

When do you plan to complete CAS 355?*

Have you completed CAS 454?*

Yes
No

CAS 454 Instructor*

When do you plan to complete CAS 454?*

Please explain your reasons for applying and what you hope to gain should you be selected to participate into the CAS 464 Practicum:*

(5-10 sentences)

Practicum Application

CAS 464: Undergraduate Practicum in Addiction Treatment or Prevention Services