COMMUNITY AND SCHOOL COUNSELING PRACTICUM PERSONAL DATA SHEET
STUDENT ________________________________________________________________
ADDRESS ________________________________________________________________
CITY/STATE ______________________________________________________________
SOCIAL SECURITY NUMBER ______________________________________________
TELEPHONE NUMBER (Home/Work) ________________________________________
WHERE ARE YOU DOING YOUR PRACTICUM?(Also list a telephone number
where we can reach your On-Site Supervisor)
_________________________________________________________________________
__________________________________________________________________________
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WHAT DAYS OF THE WEEK ARE YOU THERE AND WHAT ARE YOUR HOURS?
_________________________________________________________________________
_________________________________________________________________________
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WHO IS YOUR SUPERVISOR?
_________________________________________________________________________
WHO IS YOUR LAMAR INSTRUCTOR? ____________________________________
A PRACTICUM _____________________________________
B PRACTICUM ______________________________________