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School of Leadership & Social Change – Community Placement Application

Thank you for your interest in Community Development at Brescia University College. Please complete this application form no later than May 1, 2019. Applications received after this deadline will be considered at the discretion of the program.

This application is designed to support your intent to register in a module that includes a Community Development placement. Your responses to the questions on this application form will help us to identify your particular interest and create an effective “out of classroom” learning experience for you. Please note that all placements are off campus, and it is the responsibility of the student to arrange for transportation to and from the placement.

Street, city, province and postal code.
In what year do you plan to take the CD placement courses (3330F, 3331G, 3334B)? *
Do you have learning disabilities or special needs which should be taken into consideration in establishing a community placement? *
The committee is committed to equality of opportunity.
Application Questions
Community Placements will be determined through a collborative process among students, the faculty placement coordinator and the community partner. Students should be aware that there may be costs assoicated with the placement (e.g. parking, bus tickets) or specific requirements (e.g. police checks, health requirements). These costs are the responsibility of the student. Keeping this in mind the following are examples of community placements and projects. A few of them already involve Brescia students, while others are suggested by community partners and faculty members as good prospective practicum experiences.
Please check off the ones that are of interest to you; add some ideas if you wish.*
Checking off these boxes does not automatically guarantee an option in this area.
References

In your placement, you will be a representative of Brescia in the community. Please indicate the names, positions, phone numbers, work addresses of TWO references whom we may contact. These persons should be familiar with your character and/or your experience relevant to the Community Development placement. Please note that your references should NOT be professors who teach you in one of these programs.
First reference.
Second Reference
Student Declaration

I agree that the information written on this form is true and correct and hereby authorize the Brescia Registrar's Office to release my academic record to the selection committee of the Community Development Program.