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Student Name

Student ID

Course Number

Mailing Address During Internship

Email Address (list all)

Faculty Supervisor

Grade Type

Worksite Supervisor Name, Title

Worksite Name and Address

Work Phone

(letter grade or credit)

Beginning Date


(50 work hours/credits)

Total Hours

Class Year

(Soph., Junior, Senior)


(spring, fall, summer)

(please include zip code)

Ending Date

Approval of Dean


Note to students and instructors: All information and signatures must be provided before this form will be accepted. This form constitutes a learning contract but does no confer registration in the course. Internship courses are subject to the same academic regulations as those governing other courses, including course registration on the Personal Data Questionnaire (PDQ), summer registration form or by “Add� slip before the end of the add deadline-ordinarily the first two weeks of the semester.

The Academic Dean or a designee must approve all Internship Contracts 1. Learning Objectives a. b. c. d.

2. Activities Meet with faculty instructor as follows:

Hours per week at worksite:

Job description (can be attached is insuffcient room):

3. Student’s Responsibilities: All students shall be responsible for the Initial Report, Biweekly Reports, Self Evaluation and Final Reports Other Responsibilities, if applicable:

4. Evaluation Criteria: Student’s grade will be based on work site supervisor’s evaluation of overall performance and the faculty instructor’s evaluation of the reports. Other Criteria:

Student’s Signature


Faculty Instructor’s Signature


Faculty Advisor’s Signature


Department Chairpersons Signature


(agreement to above conditions)

(Course is relevant to students academic course study)

(agreement to above conditions)

(Course of instruction is acceptable)


this is a test

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