STUDENT AFFAIRS PRACTICUM/INTERNSHIP
ON-SITE CONFIRMATION STATEMENT
Date:__________________
Semester:____________________________
Name:___________________________ I.D..#:______________________
I have made arrangements to fulfill my Practicum/Internship experience
at the following unit:
Unit:________________________________________________________
Address:_____________________________________________________
_____________________________________________________
_____________________________________________________
Phone: (______) ____________________________
E-mail: ____________________________________
My Site Supervisor will be:
Name _________________________________________
Title _________________________________________
"I agree to supervise the above named student as part of their Practicum/
Internship experience (CNS 590 or CNS 595)."
________________________________\___________
Site Supervisor's Signature
Date
Note: If multiple units are utilized for the Practicum/Internship experience, please
complete a separate Confirmation Statement for each unit. Please return completed
forms to the faculty supervisor as soon as possible after arrangements are made with
the Site Supervisor.