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Confirm an Olds College - Practicum Student

This form is to be used by Clinics that have already been contacted by a current Olds College Student for practicums.

Student Name*

First Name

Last Name

Student Program Practicum Date*

AHT: May 2 - June 10, 2022 AHT: September 6 - October 14, 2022 AHT: January 9 - February 17, 2023 AHT: May 1 - June 9, 2023 VMR On Campus: May 2 - May 20 2022 VMR On Campuse: May 1 - May 19, 2023 VMR On-Line: June 6 - June 24, 2022 VMR On-Line: June 5 - June 23, 2023

Veterinary Practice Information

Veterinary Practice Name*

Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Have you hosted an AHT or VMR, Olds College student in the past?*

Yes No

What year(s) have you hosted students in the past?

Evaluator Contact Name*

First Name

Initial

Last Name

Evaluator Phone Number*

Evaluator Email*

Communications with Olds COllege will go to this email address.

Name of Additional Mentor who will be working with student.

First Name

Last Name

Name of Additional Mentor who will be working with student.

First Name

Last Name

Is there potential for employment after the practicum?*

Yes No Maybe

How will this student benefit from completing their industry directed field study with your practice/team.

Freedom of Information and Protection of Privacy Act

Personal information that is collected on this form will only be used in accordance with freedom of information and protection of privacy act.