| 5 Hour Volunteer Experience |
Request Form (please use additional paper if needed)
Part
I.
A. Name of Supervisor* _____________________________________________________________
B.
Phone ____________ Email
____________ Fax ______________
C. Name ofAgency ____________________________________________________________________
D.
Address____________________________________________________________________________
E.
Name of Program
____________________________________________________________________
Address
of program (if different from Agency):
D.
Description of Program & population(s) served:
Part
II.
A.
Description of responsibilities/list of duties for social work volunteer:
B.
Days of the week/times social work volunteer is needed:
C.
Requirements (i.e. training)
D.
Addition information:
* The name of the person monitoring social work volunteer and will completing end of the semester evaluation form.
Please mail to: Dr. Catherine R. Baratta, Field Education Coordinator, Dept. of Sociology & Social Work, Central Connecticut State University, 1615 Stanley St. New Britain, Ct 06052
Phone: (860) 832-3016 Fax (860) 832-2986