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This information will be shared with Internship Site Supervisors. The Internship Coordinator will mail your Agreement Form to the address you provided above. CURRENT CLINICAL PRACTICUM INFORMATION (This will be the Placement site immediately prior to your requested Internship semester.) Site Name & Location: _________________________________________ Type of Hours: ________________________________ Adult/Child/Both PREVIOUS PRACTICUM SITES Site Name Semester/Year Adult/Child/Both _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ During your Internship, what areas do you anticipate needing clock hours? CDP INTERNSHIP APPLICATION PAGE 2 Name: _________________________ GEOGRAPHIC AREA & SITES FOR INTERNSHIP General Geographic Area for Internship: _____________________________________________________________ List at least 4 specific sites with general addresses and phone #s in your requested geographical area where you are interested in completing your full time internship. Site Name:_______________________________________________ Site Address:_____________________________________________ ________________________________________________________Site Phone #s: ____________________________________________ ________________________________________________________ Any Additional Information? ___________ ________________________________________________________________________________________________________________ Site Name:_______________________________________________ Site Address:_____________________________________________ ________________________________________________________Site Phone #s:____________________________________________ ________________________________________________________________________________________________________________Any Additional Information? ___________ ________________________________________________________________________________________________________________ Site Name: ______________________________________________ Site Address:_____________________________________________ ________________________________________________________Site Phone #s:____________________________________________ ________________________________________________________________________________________________________________Any Additional Information:_______________________________ ________________________________________________________________________________________________________________ CDP INTERNSHIP APPLICATION PAGE 3 Name: _________________________ Site Name:_______________________________________________ Site Address:_____________________________________________ ________________________________________________________Site Phone #s:____________________________________________ ________________________________________________________ Any Additional Information:_______________________________ ________________________________________________________________________________________________________________ Feel free to provide additional site names/addresses/phone #s on a separate sheet of paper. IMPORTANT: When you are considering sites, please list sites that will provide you with the type of hours you need. For example, list adult sites if you need adult hours. If you will not be working with children in your internship, do not list public school sites or sites that serve children only. If you need child hours, then do not list adult sites. Please be aware that a contract between ASU and the internship is required for all sites. The contracts must be in place before you are assigned to a placement. There are many sites that have contacts already in place. Unfortunately, there are facilities that we do not have current, signed contracts. If the facility agrees to engage in a contract with ASU and a Speech-Language Pathologist is willing to supervise, then we will proceed with contract negotiations, which may be a lengthy process. What are your personal goals concerning your career? Where would you like to work/in what setting/what population? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please submit 2 copies of this completed application to the CDP Internship Coordinator. Thank You. 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