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Request for Affiliation Agreement
Please complete this form if an Affiliation Agreement is needed for a student internship, student teaching, or practicum. This assists in initiating the process as early as possible. A placement cannot begin until an agreement is finalized.
*You must use your official NAU email for the information in this form to be received. Only NAU faculty and students should utilize this form.
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* Indicates required question
Your Name (person making request):
*
Your answer
Your Email:
*
Your answer
Your Department (Ed Psych, Ed Leadership, Teaching and Learning, PEP, Ed Specialties, etc.):
Your answer
If you are a student completing this form, please indicate the responsible faculty member. Ed Leadership students can leave this question blank.
Your answer
Please select the type of placement this is for:
*
Student Teaching
Supervised Practicum (Teaching & Learning and Ed Specialties departments only)
Supervised School Psychology Practicum
School Counseling
Ed Leadership Internship
School Psychology Internship
Clinical Mental Health Counseling
Clinical Psychology PsyD Practicum
Combined School Psychology and Counseling PhD
Other (if selected, you can leave additional notes at the end of the form)
ESE 695 Internship
ECI 551
PITAS Program
Required
Is this placement request for an in-state facility, or out-of-state facility?
*
In-state
Out-of-state
Name of facility where an Affiliation Agreement is needed (please include district AND school, charter, or private facility):
*
Your answer
Address of facility where an Affiliation Agreement is needed:
*
Your answer
Facility Contact Name AND Title (person who could review and sign the agreement):
*
Your answer
Facility Contact Email AND Phone Number:
*
Your answer
Name of NAU student(s) requesting a placement in this facility (put "don't know yet" if you do not have this information at this time):
*
Your answer
What is the start date? (Month and Year)
*
Your answer
Please provide any additional information I need to be aware of. Thank you for completing this form!
Your answer
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