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Substance Use Disorders Certificate Program Field Experience Site Information Form

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Page 2
Complete

Student Information

Formal First Name

Last Name

Banner ID

Street Address

Address Line 2

City

State

ZIP Code

Phone

JCU Email

A confirmation email containing your submission will be sent to this email address.

Confirm JCU Email

Please indicate the semester you intend to take CG 418 or CG 518 Field Experience.

Note that if your site changes you will have to resubmit your site information along with a new signed Assumption of Risk Waiver.

Site Information

Complete Name of Site

Street Address

Address Line 2

City

State

ZIP Code

Supervisor Formal First Name

Supervisor Last Name

Site Supervisor Phone Number

Site Supervisor Email

Number of supervised hours agreed to for site:

Do you have a second site placement?

Complete Name of Second Site

Street Address

Address Line 2

City

State

ZIP Code

Second Supervisor Formal First Name

Second Supervisor Last Name

Second Site Supervisor Phone Number

Second Site Supervisor Email

Number of supervised hours agreed to for second site