James Madison University Department of Kinesiology Exercise Science Practicum/Internship Agency Acceptance Form Student interviewed: _______________________________________ Date of interview: _________________________ Semester Fall/Spring/Summer __________ (year) Dates of Practicum/Internship: Starting _________ Complete ___________ Agency representative completing interview: __________________________________________________________ __________________________________________________________ Position at Agency: Please check one of the following: ______ I accept this individual for placement in a: (check the appropriate category below): _____ KIN 471: Practicum - 90 hours required _____ KIN 481: 4-credit Internship - 160 hours required _____ KIN 481: 8-credit Internship - 320 hours required _____ KIN 481: 12-credit Internship - 480 hours required ______ I cannot accept this individual for a fieldwork placement at this time. In order to assist with the future placement of students, please briefly outline the basis for your acceptance or rejection. Name of Agency: ______________________________________________________________________________________ Contact Person at Agency: _______________________________________________________________________________ Address: _______________________________________________________________________________ _______________________________________________________________________________ Phone: ______________________________________ e-mail address_______________________________________ Signed _______________________________________ Date: ______________________________________________ Please discuss with the student his/her goals, and the objectives, and duties, which will be completed during their practicum/internship experience. The student should submit a copy of these in writing to the university supervisor for approval. Please return a copy of this form to: Jana Walters Department of Kinesiology 261 Bluestone Drive, MSC 2302 Harrisonburg, VA 22807 540-568-3949 (voice) 540-568-3338 (fax) walterjr@jmu.edu