PH195W Undergraduate Practicum Site Registration 

Questions marked with a * are required
Site Supervisor Email
Site Supervisor First Name
Site Supervisor Last Name
Site Supervisor Phone Number
Site Name
Site Supervisor Title
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UCI Email
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Legal Name (First and Last) Name
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Your UCI Student ID Number
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Phone Number
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Major (must check one)
What quarter are you intending or have you enrolled into PH 195W?
I certify that the site has officially offered me a placement and I have formally accepted. I certify that I have considered each question carefully and that my statements are true and complete to the best of my knowledge (Print name below in lieu of signature).
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