Field Study Course Enrollment Intent Form

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Forms

***For New and Continuing Sites***

INSTRUCTIONS:
Use this form for submitting the information necessary for enrollment in Field Study (SE 195). The information you include in this form will be sent to the Field Study 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 field study placement site; and
2) Be accepted at the placement site listed below.

Field study is restricted to Social Ecology juniors and seniors in good academic standing; students must have a minimum overall GPA of 2.0. Prerequisite courses are: SE 10, SE 194W, and the Introductory course in the area of the field study (i.e., E8, C7, or P9).

DEADLINE DATES
All Forms Due by 5:00pm

May 11	Summer Session I 2012
May 24	Students submitting forms can expect to hear back by June 1 whether or not there is space for them for SSI.
Jun 1	Summer Session II 2012

Students are not permitted to change their field placement site after the Course Enrollment Form deadline.
CLICK ON THE "SUBMIT THIS FORM" BUTTON WHEN YOU ARE READY TO SEND THE PETITION.

Course enrollment forms will be accepted up to two weeks after the deadline on a waitlist basis. These forms will be reviewed in the order received if there is space in the program after students who have met the deadlines have enrolled. Students on the waitlist can expect a response approximately 4 weeks after deadline. Students applying on the waitlist MUST inform their sites that they are applying for the waitlist and that they will not know if they have been accepted to the program until approximately 4 weeks after the initial deadline.

UCI ID Number: *

Name

First Name: *

Middle Name:

Last Name: *

Email address: *

Phone number: *

Your major: *

Second major (for double majors):

Quarter/Year of proposed field study: *

SSI 2012

SSI 2012 Waitlist

SSII 2012

Placement information

Placement site number: *

Available in the SE Field Study Catalog

Placement agency: *

Agency address

Street: *

City: *

State: *

Zip code: *

Agency phone number: *

Supervisor's name: *

Supervisor's email address: *

Hours per week: *

Number of units requested: *

Is this a PAID position?: *

Yes

Is this a new placement site?: *

New

Continuing

Description of agency and duties: *

For the field above, provide a brief description of your placement agency and the work you will be doing in the site. If you are not clear on what you will be doing, what you can do is contact your supervisor and talk with them to gain clarification. Do not assume the catalog provides all the information you need. What we need is a description of what you will be doing. For example "assisting with programs" does not provide your faculty sponsor or myself with enough information to evaluate your duties. However, "creating flyers, calling clients, staffing events" does.

Academic goals - Research Question/Hypotheres: *

What theory, idea, paradigm, hypothesis, question do you want to investigate as part of your field study? For example: I'd like to examine the therapy setting (behavior, cognitive, interpersonal, psycho-dynamic, family and group therapy) and specific therapeutic goals. In addition I want to get a more hands on experience with a therapy setting (reviewing the clinical charts and mentoring a child with mental health services) because it will give me a better idea of what a psychiatrist and clinical psychologists do. Also, it is a good idea to indicate any personal goals for your field study experience.

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