_________ COOPERATIVE EDUCATION

FALL 2008
CRN: ________________________ Day/Time: _____________________
Campus: _____________________________________________________

STUDENTS INFORMATION
Name: _____________________________________________________________
Email: _____________________________________________________________
Work phone: _______________________________________________________
Home phone:________________________________________________________
Cell phone:_________________________________________________________

SUPERVISORS INFORMATION
Name: _____________________________________________________________
Title: ______________________________________________________________
Company: _________________________________________________________
Telephone: _________________________________________________________
Cell phone:_________________________________________________________
Address:___________________________________________________________
___________________________________________________________________

SUBSTITUTE SUPERVISORS INFORMATION

Name: ____________________________________________________________
Title:______________________________________________________________
Telephone: _________________________________________________________
Cell phone: ________________________________________________________
Email: _____________________________________________________________
Signature: