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UNDERGRADUATE PROGRAM IN SOCIAL WORK

STUDENT ACCEPTANCE FORM

Agency                                                      

Contact Person                                              


I accept the following student(s) for field practicum 
commencing:

    Fall Qtr.       Winter Qtr.       Year       

Name(s) of Student(s)
1.                                     
2.                                     
3.                                     
4.                                     


I cannot accept the following student(s) for field practicum:

    Fall Qtr.       Winter Qtr. 

Name(s) of Student(s)
1.                                     
2.                                     
3.                                     
4.                                     

                         Signature                       

                              Date                                    
               
Send to:                                       
Coordinator for Field Instruction
Department of Social Work
Wright State University
277 Millett Hall
3640 Colonel Glenn Highway
Dayton, OH  45435-0001
937/775-2751 

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