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Concurrent Field Ed Placement Confirmation

Student & Internship Information

This document is to confirm that you have developed both a Placement Site and a committed Mentor for your 9-month Concurrent Field Education Internship.

Note: submission of this form is not valid until Field Education faculty has reviewed the main leadership development opportunities that will be made available to you at this location.
STUDENT INFORMATION
This question requires a valid email address.
Are you an International student? *This question is required.
  1. If your Placement Site is offering you a stipend (non-employee, non-hourly payment), be sure to have a discussion with the Registrar re: Federal documents that must be submitted authorizing your receipt of financial assistance for an off-site requirement.
     
  2. You are required to attend the Concurrent Field Education class in person. Be sure to register for the correct course section - Fall semester FE-1005, Spring semester FE-1006.
This question requires a valid email address.
PLACEMENT SITE INFORMATION
Type of Placement Site *This question is required.
City, State. Also Island Name and/or Country, if applicable
This question requires a valid email address.
PLACEMENT OPPORTUNITIES
Has your placement site offered you a stipend? *This question is required.
 
  • Please provide type, amount, and intervals of payment. For example $15 per hour, $100 per week, mileage & gas.
     
  • Any stipend provided to you is considered "Taxable income." Please work with your Placement Site to assure that the proper tax documents are being submitted. For example FW-9 (US citizens only) or adding you to their payroll system.
Please do not enter a response into the following signature boxes.

Please enter these signatures on the pdf document that will be emailed to you. You must provide a copy of the signed Placement Confirmation form to your Concurrent Field Education faculty.
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