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Agency Liaison First Name: *

Agency Liaison Last Name: *

Agency Liaison Organization (where you will supervise student): *

Agency Liaison Email: *

Student First Name: *

Student Last Name: *

Semester: * select... Spring Summer Fall

Course: * select... 701 702 703 704

I am willing to serve as agency liaison for the above named student in the above named course, semester, and year. I am not related to or a friend of the student I will be supervising, and have no direct reporting relationship with them (e.g. supervisor). I understand orientation information on the roles of faculty, agency liaison, and student in a clinical learning experience will be emailed to me, and agree to read it. I understand course learning objectives will be emailed to me, and agree to read them. I understand I will be contacted a minimum of three times over the course of the semester, with an option to respond to the course faculty regarding concerns about student progress. I agree to fill out an end-of-course evaluation on the student’s performance and progress in the clinical learning experience.

I, the above named agency liaison, do attest by filling out and submitting this form I have read, understand, and meet the requirements indicated above to be an agency liaison for the student in the course named above.

Agency Liaison Signature: *