Application Practicum Student

Year

Date of Application *

First Name *

Last Name *

Email Address

Home Address

Street Address, City, Postal Code

Mailing Address

Please complete if your mailing address is different then your street address.

Home Phone # *

Cell Phone # *

School/ Institution

School Location

Program/ Area of Study

Type of Program

Certificate

Diploma

Degree

Specify your own value:

Contact Information

Contact Name for instructor or practicum coordinator.

Contact Phone #

Contact number for instructor or practicum coordinator.

Contact Email

Contact email for instructor or practicum coordinator.

Practicum Start Date

Practicum End Date

Practicum Hours- Total

What are the total hours of this practicum?

Practicum Hours/ Week

What are the number of hours per week for this practicum?

Placement

If you are applying for placement in a particular CSCL Program, please specify the name of program(s).

Availability

Are there any days/times when you are unable to complete practicum hours?

Availability Comments

Allergies

Please list any allergies you have (i.e. pets, food) and any limitations you may have relating to them.

Relatives

If you have any relatives currently employed at CSCL, please tell us who.

Relatives .

If you have any relatives receiving service from CSCL, please indicate who are they and what program they are in.

Criminal Record Check

I want to do my practicum with adults

I want to do my practicum with children

I have no preference

If you are applying to do your practicum with adults:
If a Criminal Record Check has already been obtained through school course/ program, the student may provide a copy of recent clearance letter
Check must be obtained through the Ministry of Public Safety and Solicitor General Crimminal Records Review Program (CRRP)
To obtain a Criminal Record Check, students must complete the Consent to a Criminal Record Check form available from CSCL. Once completed, submit form to the CSCL HR Department who will contact the Ministry of Public Safety and obtain the check.
The CRRP is free of charge for practicum students

If you are applying to do your practicum with Children/Youth:
Criminal Record Check must be obtained through your local RCMP office free of charge for practicum students. Please contact CSCL HR Department for instructions.

Confidentiality Oath *

All matters and information pertaining to individuals that has been gained with the organization must be treated as confidential. Under no circumstances may an individuals information be divulged either inside or outside the organization other then to persons authorized to receive such information in the course of their duties.

**By typing your name in the space above, you are stating that you have read and reviewed the above CSCL Confidentiality Oath and that you understand that all individuals information to which you may have access is confidential and is not to be communicated except as outlined in the confidentiality oath.

Declaration *

**By typing your name in the space above, you certify that all information in this application is true and complete. You understand that if any such information is at any time found to be false, such information may be cause for discharge or refusal of practicum placement.

Additional Comments

Please click "OK" to submit your application.

Practicum Placement

What site/ program will this practicum student be placed at?

Manager

Who will be the manager responsible for this practicum student?

CRRP Clearance

Has the CRRP clearance letter been received? If no, please comment below.

CRRP comments

RCMP Clearance

Has the RCMP clearance been received? If no, please comment below.

RCMP Comments

HR Comments.

SurveyGUID

System Field: Do not change

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