Ithaca College Department of Speech-Language Pathology/Audiology
STUDENT AFFILIATE PROFILE
Student Name:
(last) (first) (middle)
Permanent Address:
(street) (city) (state) (zipcode)
Present Phone Number:
(area code)
Email Address: ________________________________________
Previous Education (undergraduate and graduate):
Clinical Experience (describe disorder types and placements):
Previous Work Experience -
Related to Speech-Language Pathology:
Unrelated to Speech-Language Pathology:
Areas of special interest:
Briefly describe yourself-what would you like the clinical coordinator and/or clinical instructor to know about you as a person:
What are your specific objectives for this clinical experience?
What are your clinical strengths? (Consider previous work experience, previous affiliations and any special training you may have had).
What clinical skills would you like to upgrade during this affiliations?
How do you learn best?
by reading by watching
by listening by doing
other:
Any other information you would like to share?
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Download Student Affiliate Profile Microsoft Word Document - Size: 28 kB |
