GEORGE BROWN COLLEGE

COMMUNITY WORKER PROGRAM

FIELD PLACEMENT REGISTRATION - FIELD 2, 3, 4 (Please circle one)                  

STUDENT INFORMATION:

Student Name:  _________________________________ ID # ___________________________

Address:           __________________________________________________________________

                        Street #:                                                                       Apt. #:

                        __________________________________________________________________

                         City                                                                             Postal Code    

Tel:                   (_____)________________________(______)____________________________

                        Area Code & Number                          Cell/Alt Tel:

E-mail:              __________________________________________________________________

Student Signature: ______________________________Date:____________________________

FIELD PLACEMENT INFORMATION:

Organization/Agency:    ___________________________________________________________

Address:                       ___________________________________________________________

                                    Street                                                                           Unit/Suite

                                    ___________________________________________________________

                                    City                                                                              Postal Code

Field Supervisor:           __________________________________________________________

Tel:       (_____)_________________________   Fax: (____)_____________________________

            Area Code & Number                                                  Area Code & Number

E-mail: ______________________________     Website: _______________________________

Period of Field Placement: _______________________ to _____________________________

Days of Field Placement:           Monday           Tuesday      Wednesday           Thursday          Friday     (Circle days)

AGREEMENT:

I agree to provide supervision as required by the Community Worker Program.

Placement Supervisor (signature) ________________________________Date: ______________

FACULTY INFORMATION:

Faculty Field Advisor:      ______________________________________Date: ______________

Faculty Phone #: _______________e-mail: _______________________  Fax: 416-415-2646

Distribution: Copy to Faculty ____    Copy to Field Supervisor ____          Copy to Student ____