PETITION TO CREATE AN INDEPENDENT MODULE CENTENARY COLLEGE OF LOUISIANA
Student should submit completed petitions to the Registrar’s Office no later than November 15 for an independent
module they intend to complete in the spring term, and no later than April 1 for an independent module they intend to
complete in a summer or fall term. These deadlines are firm, please be attentive to them.
Date this petition received
Name (printed)
Campus Box #
Signature
Phone #
Email (for communications about petition)
Classification
Major
Expected Graduation: Year
Semester
Degree Plan on file with the registrar
Y N
Dates of when you plan to actually complete this independent module?
When do you plan to register for this independent module? Semester
Year
My reasons for requesting an independent module
: (Feel free to attach any necessary supportive material. Describe the
compelling reasons the committee should consider approval of your substitution for the regular May Module.)
Attach a complete syllabus for your proposed independent module course. Your syllabus must include:
a course description, including clearly defined learning goals/outcomes;
the hours of credit desired and a time audit justifying those credit hours;
the name and position of the faculty member who will be supervising and evaluating the independent module;
the tentative locations and dates of all learning activities, and which activities and meetings are already confirmed/arranged and
which are not yet firm;
the methods of student evaluation (e.g., papers, presentations, journals, etc.); and
the required readings and other instructional foundations (e.g., films, discussions, interviews, etc.).
Please note: Independent modules are “concentrated study for a short period on topics of… interest not normally offered.”
Independent modules that involve travel off-campus or out of the country may be subject to Centenary’s insurance regulations.
If you are also seeking CU credit for this independent module, you should attach a 2-3 page typed proposal which
explains the cultural experience you intend to have and addresses all of the following questions listed below:
What culture will you study?
How is this culture different from your own?
Why would you like to study this particular culture? Why is it important to
you?
What knowledge, personal gratification, and/or perspective do you hope to gain from this intercultural experience? Be specific.
If you are proposing a module inside the US, explain how the culture you are applying to study is substantially distinct from
mainstream US culture.
Any Independent Culture Project must be completed under the guidelines for the CULTURE program.
For students studying a sub-culture in the USA, they must complete no fewer than 45 hours of activities dedicated to learning
about or from the intended culture of study.
For students studying a culture in another country, they must spend 14 days within the culture, inclusive of travel time. Those
hours/days include
interactive time with the unique population with the intended culture of study. Examples of interactive
activities include, but are not limited to: conducting interviews, attending traditional services/ceremonies, volunteering with a
group associated with or supporting the culture under study, etc.
Please note: If your proposal is approved by the Trek Committee, you will be required to complete additional paperwork with both
the Office of Global Engagement and Centenary’s Department of Public Safety
.
Other interested parties can include or attach their comments and documentation to this form:
(The committee welcomes
any details, supporting documentation, regardless of whether or not you approve of the action requested.)
Student should acquire the necessary signatures regarding this independent module proposal:
Course Dept
Course Title
Signature of instructor supervising this independent module
Date
Signature of advisor approving this independent module
Date
Business Office signature indicating financial arrangements made
Date
Risk Insurance Form completed & submitted, Risk Officer
Date
The remaining sections of the petition will be completed by the Registrar and other campus offices;
the student is not responsible for the sections below.
Centenary Registrar will comment in this section of the petition:
Signature
Date
Decisions, comments and/or recommendations regarding this petition:
Module
Approved
Denied
Other
APC Chair Signature
Date
CU Credit
Approved
Denied
Other
Comments
Trek Chair Signature
Date
Provost’s Office
Approved
Denied
Other
Comments
Provost’s Office Signature
Date
APPEAL OF THE COMMITTEE’S DECISION
Direct any appeal to the Provost, who can request that the committee reconsider its decision, but an appeal must include new and
relevant information or documentation. You cannot appeal a decision solely on the grounds you disagree with it. An appeal decision
is final, cannot be appealed further.
Appeal Approved
Appeal Denied
Provost’s Signature
Date
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