Public Health Practicum - Enrollment Intent

INSTRUCTIONS:

Use this form for submitting the information necessary for enrollment in Public Health Practicum, PUBHLTH 195W. The information you include in this form will be sent to the Practicum Program Director as well as your faculty sponsor. Please be sure to complete each portion accurately and completely. Incomplete applications will not be approved.

Prior to completing this form, students must:

1. Interview at prospective Public Health Practicum placement sites; and
2. Be accepted at the placement site listed below.
3. Have met the pre-requisites.

Public Health Practicum is restricted to Public Health juniors and seniors in good academic standing; students must have a minimum overall GPA of 2.0. Prerequisite courses are: PUBHLTH 1 and PUBHLTH 2.

DEADLINE DATES:

• Fall Session 2008: Aug. 1, 2008 5:00pm
• Winter Quarter 2009: Nov. 7, 2009 5:00pm
• Spring Quarter 2009: Feb. 13, 2009 5:00pm

Students are not permitted to change their practicum placement site after the Enrollment Intent Form deadline.

UCI ID Number: *

Full Name

Full name as it appears on your transcript.

First Name: *

Middle Name:

Last Name: *

Email address: *

Email address where we can contact you (preferably UCI email address - i.e. jdoe@uci.edu)

Phone Number: *

Local Phone number with area code, format (949) 555-5555

Your major: * select...Public Health Policy, BAPublic Science, BS

Quarter/Year of Proposed Practicum: *

Fall 2008

Winter 2009

Spring 2009

Placement Site Information

Placement site number: *

Available in the Public Heath Practicum Catalog.

Placement agency: *

Placement Agency Address

Street: *

City: *

State: * select...CADC

Zip code: *

Phone:

Phone number with area code, format (949) 555-5555

Supervisor's Name: *

Supervisor's Email:

Hours per week you will be at your placement site:

Is this a new placement site?: *

New

Continuing

Is this a NEW placement site or are you currently enrolled in practicum and planning to CONTINUE at the same placement site?

Provide a brief description of your practicum agency and the work you will be doing in the site: *

What are your ACADEMIC goals for this project?: *

What are your ACADEMIC goals for this project? Discuss what you intend to learn or achieve with this practicum experience. (Be Specific)