Student Internship Site Request

Admin Info

Form category

Other

STUDENTS SHOULD ONLY SUBMIT THIS FORM AFTER MEETING WITH AND CONFIRMING PLACEMENT WITH THE AGENCY OR ORGANIZATION.

All students engaged in academic courses at locations not listed on this site, including fieldwork, internship, and field studies courses, must complete this Student Internship Site Request form. Students who do not successfully complete the placement process or submit this form cannot receive credit for their internship. These students must contact their instructors. To successfully submit this form, students must acknowledge they understand and agree to the terms, and submit with signature.

Students engaged in observations, field trips, or one-time meetings for credit, courses, or class projects must complete a Field Trip Form.

Student Identification Information

Student Name *

NetID *

Student Email Address *

Course Information

Course Department, Title, Number *

Instructor Name *

Instructor Email Address *

Site Information

Name of Agency/Service Site *

Name of Supervisor/Your Contact at Service Site *

this is the agency or organization representative who has approved your service experience

Email of Supervisor/Your Contact at Service Site *

Please be sure this information is accurate. Notification of submission will be sent to the contact you have identified.

Expected Start Date *

Month

Day

Year

Expected End Date *

Month

Day

Year

Expected number of hours *

Are you being paid (minimum wage of greater) for service hours? *

Yes

Will you require a CPT to engage in this internship? *

Yes