ࡱ> <>;]  bjbjjj 0)b)b !P P 8,!2Hdddd?"au  $3"$ ?? dd Fdd  : Hd[bFh l  0!r.% %%L6,/ !%P B : CENTRAL CONNECTICUT STATE UNIVERSITY Department of Counselor Education and Family Therapy SCHOOL COUNSELING - APPLICATION FOR INTERNSHIP - CNSL 591 Eligibility Requirements: 1. Complete all prerequisite courses, core courses, and the majority of specialized courses especially CNSL 520, CNSL 522, CNSL 524, CNSL 526. (The capstone, i.e., thesis or comprehensive exam, are usually done during the internship year). NOTE: It is expected that students will have completed a minimum of 39 credits before taking the internship. Provide proof of professional liability insurance Certified teachers with a minimum of 3 years experience must provide a copy of their teaching certificate to do a 600 hour internship Effective July 1, 2010, Connecticut law requires all students in educator certification programs to undergo state and national criminal history background checks before participating in school-based field experiences. You will be responsible for the cost of the background check and will be provided with the necessary consent forms and other documents needed to conduct it. As part of the background check, you will need to be fingerprinted. If you fail to pass the background check, you may be unable to complete your chosen degree program at 91Ʒ Connecticut State University. The University will not be responsible for your inability to complete your chosen degree program. I wish to apply for admission into the CNSL 591, Supervised Field-Based Internship in School Counseling for the following semesters: Semester:  FORMCHECKBOX  FALL  FORMCHECKBOX  SPRING YEAR: __________________________ NAME: __________________________________________________________ DAYTIME PHONE: _________________________ DATE: __________________________ E-MAIL: ____________________________________ ADVISOR NAME: ______________________ Number of graduate credits completed: _______________________ Site where practicum (CNSL 503) was completed: ________________________________ ARE YOU DOING A ONE SEMESTER 600 HOUR INTERNSHIP: yes ____ NO _____ Internship Site (if selected) School Name: Address: Site Supervisor: Telephone Number: EMAIL: Please see your advisor and refer to Student Handbook for more information about finding an appropriate internship site. ADVISOR CERTIFICATION - I have reviewed this students application and file and certify that he/she is ready to begin the internship. ______________________________________ ____________________________ Advisor Signature Date     SC-5 Revised 6/18 %&;G[\mpra s  E x  #$234GJHITew¸«¸ž˜’‹|x‹h:vh`h~y h~y;CJ hWX;CJ hGCJ h#)$CJjthWXCJUjhWXCJUjhWXCJU hWXCJ hQhQhdr h '5\ h;>5\ h[ 5\ h@5\ hWX5\ hWXCJhWX/%&[\ E x y deH & F hh^hgdQ & F hh^h hh^h` !$a$HI=>KTew~~ &dPgd:vw~ z}   h&$hr hWXCJ h[ CJhojhoUh:v6CJ]hr6CJ]hWX6CJ]hWX hr5CJ h~yCJhrh~y5CJhrhr5CJhrhr6CJ hrCJ hWXCJ h&$;CJ#   .:p6T8/ =!"#$ % tDeCheck4tDeCheck5s2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH 8`8 Normal_HmH sH tH >@>  Heading 1$$@&a$CJB@B  Heading 2$$@&a$5CJB@B  Heading 3$$@&a$>*CJDA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 2B2 Body Text6:P@: Body Text 2;CJ4@4 Header  !4 @"4 Footer  !H2H &$ Balloon TextCJOJQJ^JaJN/AN &$Balloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<   #w  H   #3 G$G$8@0(  B S  ?Check4Check5 $ 4 ΀ ΀ ΀ ΀ ΀  $$ 9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType   4Z\pasEGJdv}   ;G\pEExddGv}    i_~vgk>^`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.hh^h`o(.vgki_vgk         _L] ('wdl/[ WXn&$#)$ 'ox/6T8O<@QAV:Y:vo~yDn`r[i|;>G)<0ga;1r&``Xm! @   @UnknownG.[x Times New Roman5Symbol3. .Cx Arial9. . Segoe UIA$BCambria Math"hh4kfEsfdgzozo!r4 3QHP?:v2!xxC $CENTRAL CONNECTICUT STATE UNIVERSITYFaculty6Rosario, Marian (Counselor Education & Family Therapy)  Oh+'0 DP p |  (CENTRAL CONNECTICUT STATE UNIVERSITYFaculty Normal.dotm8Rosario, Marian (Counselor Education & Family Therapy)14Microsoft Office Word@0@YB@ y@zo ՜.+,0 hp  CCSU  %CENTRAL CONNECTICUT STATE UNIVERSITY Title  !"#$%&'()*,-./012456789:=Root Entry Fxe?Data 1Table%WordDocument0SummaryInformation(+DocumentSummaryInformation83CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q