Name of Student _________________________________Student ID # _____________________________

Address __________________________________________________________________________________________

_________________________________________________________________________________________________

Home Telephone____________________________ Work Telephone _____________________________

E-mail address ____________________________________ TTN Site___________________________________

Place Presently Employed ____________________________________________________________________________

Semester and year desired for counseling internship _____________________________

School system (include district or county) preferred for placement _____________________________________

_________________________________________________________________________________________________

School System address _____________________________________________________________________

_________________________________________________________________________________________________

School preferred for assignment ______________________________________________________________

School address____________________________________________________________________________________

________________________________________________________________________________________________

Have you already made arrangements with the school? _____ Yes _____No

Contact person & phone number_______________________________________________________________________

Starting date ___________________________

I agree to report to the school as subsequently assigned. I also assume the responsibility for reporting any change in my plans to the Director of the Office of Teacher and Counselor Education Services, College of Education, Old Dominion University, in sufficient time to prevent inconvenience to school personnel.

_________________________________________
Signature of Student

PLEASE DO NOT WRITE BELOW THIS LINE

To the School System:

We are requesting placement for an undergraduate student in Human Services, requiring a minimum of 400 hours.

We are requesting a placement in:

Elementary School ( ) _____________________________________________________

Middle School ( ) _____________________________________________________

Senior High School ( ) _____________________________________________________

Approved: _________________________________________________________________
Coordinator, Human Services Program

Approved: _________________________________________________________________
Director, Office of Teacher Education Services