Field Practice Application

Field Practice Application

Information provided on this form will determine eligibility for CORR 496 (Corrections Field Practice) and to facilitate placement. A copy may be provided to the field supervisor. Please respond to all items. If you have questions, contact Jessica McLaughlin at 507-389-5601 or .

Please read all the documents found on the Field Practice webpage at

This form must be completed and turned in to Jessica McLaughlin during your initial meeting to discuss Field Practice.

Name______Date______

Tech ID______Phone Number______

Email Address ______

Permanent Address:Street address______

City, State and Zip ______

Local Address:Street address______

City, State and Zip ______

In case of emergency, notify ______Phone______

Major (s) and Minor (s):

Cumulative GPA:______

Licensed Driver: Yes or No Car available during placement: Yes or No

Preferred terms for placement: Fall_____ Spring _____ Summer _____

Number of Credits = 10 = a minimum of 450 hours spread over the semester. 400 of those hours must be completed at the internship; up to 50 hours may be used for transportation to/from and attendance at Capstone meetings.

Briefly describe your career objectives:

______

Describe the setting you prefer for your Field Practice and the population(s) you would most be interested in working with:

______

Have you completed the courses required for the major? Yes or No

Have you applied for graduation? Yes or No

Are you approved for graduation? Yes or No

Have you purchased the liability insurance? Yes or No

The following questions relate to information that correctional agencies require in making the decision whether or not to offer an internship opportunity. Your responses will not necessarily prevent you from entering fieldwork but may require discussion with the field agency prior to placement. If your answer to any of the following questions is “yes”, please explain thoroughly on a separate sheet and submit it to Jessica McLaughlin or schedule a meeting to discuss any concerns with Jessica McLaughlin. It is of vital importance that you are open and honest about the following questions. Correctional agencies may require a background check and need to know if any of the following situations applies to you. If you are to error, error on the side of including too much rather than too little in revealing any problem with law violation, chemical use and/or mental health concerns.

Have you ever been adjudicated as a juvenile or convicted of an adult criminal offense (exclude minor traffic crimes)? Yes or No

Have you ever been charged with sexual harassment or sexual abuse of clients or colleagues? Yes or No

Have you ever been dismissed from a job, internship, volunteer, or other field related experience for sexual harassment or sexual abuse of clients or colleagues? Yes of No

Have you ever been treated for chemical dependency? Yes or No

Have you ever been treated for mental illness or emotional problems? Yes or No

Have you ever been denied, dropped from or failed an internship or other field based learning experience? Yes or No

Do you have any physical condition that will necessitate special consideration in selection of a field placement? Yes or No

If so, please describe your situation including need for special access, restrictions on activity, possibility of acute episodes such as seizures, diabetic reactions, etc.

If there is any other information about you or your background that is not addressed in this application but which might be relevant to your placement, please provide it also. Use separate pages and submit it to the Field Practice Coordinator.

Employment and Volunteer History: Begin with most recent experience. Include any special skills and interests that may be relevant to the proposed internship. You may submit additional relevant information to Jessica Mclaughlin, or may submit a resume.

Authorization and Certification

I give my permission for a copy of this application and related materials including my transcript to be provided to prospective field supervisors. To the best of my knowledge, the information provided in this application and all related materials is true and accurate.

Name ______Date ______

** On very rare occasions, a field practice placement will be terminated. If that situation occurs, the corrections program has a process in place to address such problems. Options may include, but are not limited to: permanent termination of the internship, a plan to resolve the issues, consideration of a new field practice placement, and reconsideration of the major. Hopefully, such an event will not occur, but in the event it does, there is a process in place to address the situation.**