Proposal for Field Placement

Please submit this form to CCS staff: 
$	Theme Year and Reflection Year students by May 15.  
$	Leadership Development Module students by June 30.  	

Theme Year:
Please complete (in full) and forward (by fax, mail or electronically) the following form outlining your field placement proposal to CCS staff.  Prior to a final decision on a placement, staff will have a discussion with the potential facilitator and diaconal/vocational mentor.  Please ensure that your conversations with people in potential field placement(s) convey that staff approval is required before any placement can be finalized and that you are initially exploring possibilities.  It is essential that the status of your conversations is clear. 

Please see the Process for Setting Up the Field Placement (in Field Kit) for further details.

Student
Name
Address
City:					Province:			Postal Code
Phone: (W)		(H)		Fax:			e-mail

Potential Theme Year Field Site
Name:
Street Address:
City:					Province:			Postal Code:
Phone: (W)				Fax:			e-mail

Potential Learning Facilitator
Name:
Address:
City:					Province:			Postal Code:
Phone: (W)		(H)		Fax:			e-mail

Potential Diaconal/Vocational Mentor
Name:
Address:
City:					Province:			Postal Code:
Phone: (W)		(H)		Fax:			e-mail

Profile of the Potential Field Placement
Briefly describe the site, including what people participate in this ministry setting as staff and key volunteers.

Briefly describe any previous relationship with this ministry setting or type of ministry setting.

Attach your learning plan draft.  Identify how this potential field placement connects to your goals for this theme year and supports your learning plan?  

Outline the possible learning opportunities and roles that you might assume in this placement and indicate how they relate to your learning goals/plan.

Describe how you have assessed this possible placement (With whom have you spoken?  What kind of response has there been?).

How are you feeling about the potential learning facilitator and diaconal/vocational mentor? 

Are there any concerns that should be noted now?

Is this the only field placement you explored?  Are there other options?

Have you been able to identify potential members of a Local Committee?

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Approved by: _________________________________
(Primary staff person)

_____________________________	
(Date)