University of Vermont

Application for EDSS 239 Service Learning Internship

Student Information (*Where you can be reached during the internship)

First Name:
Last Name:
MiddleName:
Phone:*
Address:*
Email:*
City:*
State:*
Zip:*

Academic Information

College/School:
Major:
Expected Graduation:
Class:

Placement Information

Employing Agency:
Intern Position:
# hours/week:
# of Credtis:
Semester:
Compensation Available? Wages None
Employer Address:
City: State: Zip:

Supervisor

First Name:
Last Name:
Title:
Email:
Phone:
Web Address:

Work Plan

Brief Description of Employer (its functions and purpose):

Brief Job Description:

Description of Training and Supervision:

Learning Goals and Objectives (describe what you wish to learn from this internship):

After submitting this form, please print a copy for the SLI Program Instructor to hand in with the SLI Contract, as well as follow the additional steps...
Please follow the link on the bottom of the next page (your confirmation page) to return to the list of STEPS to finish your process. Thank you.

Last modified August 26 2013 02:29 PM