
AGENCY INFORMATION
Agency name:
Street Address:
City:
State:
Phone:
E-mail:
AGENCY CONTACTS
Contact Person #1:
Last Name:
First Name:
Phone #
E-mail:
Educational Background:

Contact #2:
Last Name:
First Name:
E-mail:
Educational Background:

Contact #3:
Last Name:
First Name:
E-mail:
Educational Background:

STUDENT INFORMATION
Type of Student:
Summary of Student Opportunity:
Quantity of students your agency can accommodate?
How many hours a week can you use a student?:
What days of the week did you want the student to work?:	Monday Tuesday Wednesday Thursday Friday Saturday
What times would you need a student?
Which semester do you need the student(s)?	Semester 1 Semester 2
Does the student need a car?	Yes No
What Medical Tests would be required?	TB HB Other:
Will there be home visits?	Yes No
Will background checks be required?	Yes No
If yes, what type of background check?
Will the agency obtain the background check?	Yes No

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Social and Cultural Sciences Majors

Check out our suggested curriculum for our four majors:

• Anthropology
• Criminology and Law Studies
• Social and Welfare Justice
• Sociology