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:	Select One Arts & Sciences Agriculture & Life Sciences Education & Social Services Engineering & Mathematics Medicine Nursing & Health Sciences Rubenstein School Business Administration Graduate College	Major:
Expected Graduation:	Select One May 11 December 11 May 12 December 12 May 13 December 13 May 14 December 14 May 15 December 15 May 16	Class:	Select One First Year Sophomore Junior Senior Graduate

Placement Information

Employing Agency:		Intern Position:
# hours/week: # of Credtis: Semester: Select One Spring 2011 Summer 2011 Fall 2011 Spring 2012 Summer 2012 Fall 2012
Compensation Available? Stipend Federal Work-study Award 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 28 2012 02:26 PM