<p> Health Promotion and Physical Education (HPPE) FIELDWORK PETITION FORM ALL INFORMATION MUST BE TYPED</p><p>Part A: STUDENT INFORMATION</p><p>Name: FORMTEXT ID#: E-mail: @ithaca.edu</p><p>Local Permanent Address: Address: ______Cell: Permanent Phone:</p><p>Major: Total credits earned to date: Minor: Credits currently enrolled in: Projected Graduation Date (month, year): Academic Advisor: </p><p>Are you attending Ithaca College on an International Student Visa? YES NO When you complete this experience will you be registering as a Washington Campus Student? YES NO</p><p>Part B: COURSE INFORMATION For HLTH and HPS Fieldwork will need to consult with Jules Boles, Internship Coordinator before filling out the information in this section. For PHED Fieldwork, you will need to consult with Andy Byrne.</p><p>Ithaca College Faculty Julie Boles Andy Byrne ______Supervisor: Other (specify) </p><p>Course you plan to be registered in: HLTH-34900 Fieldwork in Health (.5 – 6 credits) PHED-34900 Fieldwork in Physical Education (1 - 6 credits) HPS-39600 Fieldwork in Health Service Administration (3 credits) Other (specify course # and title) Course Number: Course Title: </p><p>Number of Credits: Semester of registration: Fall Spring (.5 – 6.0) (choose one) Winter Summer</p><p>Estimated Time Allotments++ + = WORK HOURS RELATED HOURS TOTAL HOURS Hours of work at site Hours of related study and/or Students must complete faculty consultation 60 hours per credit</p><p>++ Since this is a work placement, students are given credit on the basis of the work they do. Thus, commuting hours to and from the work site can not be included in the overall tally of hours.</p><p>Part C: FACILITY/SITE INFORMATION</p><p>Name of Facility: Site Supervisor Information Facility Address: Name: Street Title: City, State, Zip Phone #: ______Fax Number: E-mail: </p><p>Is this internship site within a 500 mile radius of Ithaca College? YES NO</p><p>Start Date: Completion Date: </p><p>HPPE Fieldwork Petition Form Page 1 of 3 Part D: Design Statement (all information must be typed)</p><p>Career Goals:</p><p>Learning Objectives:</p><p>Location:</p><p>Dates: Hours per week: </p><p>Description of the Agency:</p><p>Student Preparation for Experience:</p><p>Nature and Scope of Study:</p><p>Interaction with Faculty Supervisor:</p><p>Grading System:</p><p>Part E: STUDENT SIGNATURE (student must sign and date in ink) I give the Internship Coordinator permission to discuss my academic performance and professional behavior with the site supervisor(s). Also, my signature indicates agreement to and responsibility for fulfilling all course, department, and site requirements pertaining to this fieldwork/internship experience.</p><p>______Student Signature Date</p><p>When complete, students need to obtain the appropriate signatures from the IC faculty. Once all faculty signatures have been obtained, this form should be given to the Office of Experiential Learning in Room 322B located in Smiddy Hall. </p><p>HPPE Fieldwork Petition Form Page 2 of 3 Part F: APPROVAL SIGNATURES</p><p>Internship Coordinator Date</p><p>Academic Advisor Date</p><p>Department Chair Date</p><p>Office of Experiential Learning Date</p><p>HSHP Dean’s Office Date</p><p>HPPE Fieldwork Petition Form Page 3 of 3</p>