Human Services Leadership

Field Experience Request Form

Field experience requests will be considered on a case-by-case basis. You will be notified of the outcome of your request and/or if additional information is required via your UW Oshkosh email.

Provide a detailed description of the exception you are requesting and your rationale for why your request should be granted. Submit all relevant details, including contact information for agencies or individuals as applicable.

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Date*
MM slash DD slash YYYY
UW Oshkosh Email*
Student Name*
First Last
Address*
Street Address City State ZIP Code
Which HSL undergraduate program are you currently enrolled?*
What semester and year will the field experience be completed?*

Example: Fall 2018 or Spring 2019
Field experience for which you are submitting a request?*
Thoroughly describe your request:*
Rationale for request - Provide a detailed rationale for why your request should be granted and include all relevant information.*
I would like to meet to discuss this request
- Yes
- No
If applicable to request, provide the field placement agency contact information.
Prior to submitting this form, confirm with the site that they are willing to accept your placement and provide the contact information below
Agency Supervisor
First Last
Agency Supervisor Phone Number
Agency Supervisor Email Address
Agency Address
Street Address Address Line 2 City State ZIP Code
Hidden
Date
MM slash DD slash YYYY

Human Services Leadership

Field Experience Request Form

If applicable to request, provide the field placement agency contact information.