Practicum Student Request Form

Name

First Last

Phone

Email*

Ministry Department*

How many students do you need per campus? Please list each campus you are requesting for and the number of students on that campus. Example 217- 3 students (We will place in Eugene if possible)*

What day(s) of the week/ time slots are required/preferred*

Weekly Tasks*

Please list and describe weekly task lists that may be assigned to your practicum students.

Special Projects

eg. Youth Night, preaching at Mannahouse Kids, ect.

Approximate weekly hours?*

Will you be directly overseeing your practicum students?*

Yes
No

If you answered no above, list the name & number of delegated direct oversight

I plan to connect pastorally with my practicum student at least?*

Once a week
Bi-monthly
Once a month
Never, I don't like people

Please select one

Desired Skill Set*

Approximately how many total students do you need?*

Is there anything else our placement team should be aware of?