Agency Acceptance Form - James Madison University

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
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)