Honors Application Form

Name     Student Identification Number

Address City

State        Zip Code

Phone

Email Address

Faculty Advisor’s Name    William J. Pellicio                                 Phone 825-1125

Dept. Human Services                            Faculty Advisor’s Banner ID # ________________

Email wpellicio@ccri.edu                                                               Project Proposed For:  Fall 07

Course Section Information:    Select Course Number HMNS 1040 600 (Drugs ONLINE) HMNS 1040 150 (Drugs Flanagan) HMNS 1040 001 (Drugs Knight) HMNS 2110 001 (Social Work Knight) HMNS 2110 301 (Social Work Providence)

Course Title  Select Course Drugs and Human Behavior Introduction to Social Work

Course Reference Number (CRN) __________________

Title for Project:   Lakota Child Welfare Project

How many total Honors Projects are you applying for this semester?  select one one two

How many Honors Projects have you completed at CCRI (not including this proposal sheet)?

select one none one two three four or more

Will you be completing your program requirements for graduation within the next year? select one yes no

If yes, for select one December 2007 May 2008 December 2008

For Honors Program Coordinator: HONR ________ - ________

Objectives and Activities _____________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Final Product (be specific!) ___________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Do you plan on participating in the Honors Forum at the end of the Spring Semester? Yes

No

How will the final grade be determined?

__________________________________________________________________________________________

__________________________________________________________________________________________

Conference Schedule (frequency and/or specific dates) _____________________________________________

Beginning Date _______________ Completion Date _______________

I understand and agree to the above information and confirm my eligibility for participation in the Honors

Program. I also understand that if I choose not to participate, I must notify the Honors Coordinator before the

“last day to drop a course without prejudice” as designated by the Registrar.

Student signature ____________________________________________________

Date ________________

Faculty Advisor signature _____________________________________________

Date ________________

For Honors Program Coordinator:

Date received ____________________

Recommended Approval ____________________

revised September 2007