NAME ________________________   Classification______  Semester ___   Year________
Address                                                                                      Telephone                         
E-mail                                                     U of A Student #                                                   

Course Number:  COMM 4913 or COMM 5913 (circle one)
Instructor                                                     Campus Address                                              

Placement                                                                                       Telephone                     
Address                                                                                                                              
Supervisor                                                                                                                           

Discuss the nature of your placement or project and what your specific responsibilities will include:

What are your learning objectives for this placement and in what way will this experience allow you to accomplish these objectives?

Criteria for evaluation and grading (papers, logs, evaluations by field supervisor, etc.; attach additional documentation if necessary):

Arrangements (indicate frequency) for on-campus meetings with instructor:

                                                                                                                                         
Student’s Signature                       Instructor’s Signature                Dept. Chair’s Signature

                                         
Supervisor’s Signature