HSV Agency Sign Up

Please fill out the information below if you are interested in hosting a field experience student in our human services or substance abuse certificate program.

Organization Name  

Organization Address  

Organization Phone Number  

Organization Website

Terms your organization can host students for a 45-hour shadowing experience Please select all that apply

FallSpringSummer

Population Served Please tell us more about the population and services your agency provides. Please check all items that apply.

Men Women Children Youth/Adolescents LGTBQ Elderly Disabled Homeless/Housing Low-income Families Mental Illness Incarcerated/recently incarcerated Substance Abuse Veterans Nursing Home Residential Program Hospice Education Services Childcare Healthcare Interpersonal Violence Advocacy/Community organizing Food Insecurity/Hunger Other (please clarify below)

Population Served If you selected "other" in the Population Served list, please specify the population served below.

Potential Activities Please tell us a little about the activities you have in mind for our students so we can find the right student for your organization based on their skills.

Schedule Preferences If there are specific days or times that will or will not work for students to be at your agency, please let us know. We want to honor the needs of your agency to serve your clients/consumers.

Background Check Required?  

Yes No

Contact Name   Please provide the name and contact information for the person we should contact to coordinate field experience placements.

Placement Contact Position Title   (i.e. Director, Volunteer Coordinator, Program Manager)

Placement Contact Certificates/ Licenses (i.e. CWDP, BA, LCSW, MA, LMSW)

Placement Contact E-mail Address  

Placement Contact Direct Phone

Student Capacity   How many CNM students would your organization be willing to potentially accept per term? (Spring, Summer, Fall)

Comments/ Additional Information   Please provide any comments or additional information you would like us to consider.

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