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9.1: Acknowledgement Form

  • Page ID
    146748
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    Human Services/Social Services/Addiction & Recovery Services

    Student Acknowledgement Form

    _____(Initial) I have read and understand the Student Handbook as posted on the HACC Human Services website.

    _____(Initial) I acknowledge that I have read and understand the Essential Qualifications for Programs:  Human Services. I also acknowledge that I am capable of performing the essential abilities and skills outlined in the Essential Qualifications with or without reasonable accommodation. I understand that if I am no longer able to meet these Essential Qualifications, I will immediately notify the Program Director. The Essential Qualifications information is located in the Student Handbook.

    _____(Initial) I acknowledge that I have read, understand, and will adhere to the National Organization for Human Services (NOHS) Ethical Standards for Human Services Professionals as posted on the NOHS website.

    HUMS 215 Field Work Practicum The following statements refer to information about Practicum.

    _____(Initial) I understand that it is my responsibility to submit the Intent to Enroll in HUMS 215 Form no later than midterm of the semester preceding the semester in which I plan to register for the Field Work Practicum (i.e., submit intention in the spring for summer or fall semester; submit intention in the fall for spring semester).

    _____(Initial) I understand that all students who are entering HUMS 215 Field Work Practicum must submit any clearances required by the Practicum site, such as a Pennsylvania Child Abuse History Clearance, FBI Check, and State Police Criminal Record Check, at the student’s expense, prior to starting the course. If a student has committed certain crimes, that student may require special permission from a practicum site for placement. HACC will make every effort to allow students to complete their program of study in the Human Services/Social Services/Addiction & Recovery Services fields but cannot require facilities to accept students for practicum.

    _____(Initial) I understand that some practicum sites do not allow tobacco use, and some practicum sites may require specific testing (e.g., drug testing) at the student’s expense.

    _____(Initial) I understand that in the event I do not earn a grade of C or higher in the HUMS 215 Field Work Practicum, cannot demonstrate the abilities and skills outlined in the Essential Qualifications, violate the NOHS Ethical Standards, or have a legal violation during the time of enrollment in the course, I will need to meet with the Program Director and/or designee to discuss whether I will be able to repeat the course and/or continue in the program.

     

    ________________________________________________

     

           

    _________________

    Applicant Signature          Date

     

     

     

     

    ________________________________________________

     

           

    _________________

    Print Name          HACC ID

     

     

     

    ________________________________________________

     

         

     _________________

    Instructor/Witness             Program/Major

     

     

     

     

    revised 10/05/2021 WDB


    9.1: Acknowledgement Form is shared under a CC BY license and was authored, remixed, and/or curated by Wendy D. Bratina.

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