Student Intern Name: ________________________________________
Student Number: ___________________________________________
Student Address:
Other student contact information:
Phone:
Daytime _________________ Evening _________________ Email: __________________
Course number 3369 (three credit hours) section __________
Course number 3469 (four credit hours) section __________
Internship Application approved and on file with internship coordinator: ___ yes ___no
Internship Mentor Contract complete and on file with supervising faculty: ___ yes ___ no
Internship Site (as listed on Internship Application) _________________________________________
Internship Mentor Name ________________________________________
Internship Mentor contact information__________________________________________________________
Prerequisites:
___yes ___no Overall GPA 3.0, psychology GPA 3.0
___yes ___no Junior or Senior status and completed course work appropriate to the project as determined by the
faculty supervisor and the internship mentor
Student Requirements:
___yes ___no That the project, or work plan, be defined well in advance of registration deadlines and be acceptable to the student, the faculty supervisor, internship mentor, and the internship coordinator and is unpaid throughout the internship.
___yes ___no A mid-semester report of student satisfaction and progress made (this may be formal or informal at the discretion of your facultysupervisor) will be provided to the faculty supervisor from the student.
___yes ___no A mid-semester report will be provided to the faculty supervisor by the internship mentor (this may be formal using the Mid-Term Internship Mentor Feedback Form or informal at the discretion of your faculty supervisor); the student will facilitate this process as needed.
___yes ___no An End-Term Internship Mentor Feedback Form will be submitted from the internship mentor; student will facilitate this process as needed.
___yes ___no A final report submitted by the first day of finals (this should be a formal paper of at least 1000 words in length, APA style) to your faculty supervisor.
___yes ___no A written logbook documenting total hours worked submitted to your faculty supervisor by the first day of finals signed/initialed by the internship mentor.
___yes ___no 3 credits, 100 hours minimum of documented work
___yes ___no 4 credits, 120
hours minimum of documented work
___yes ___no Internship will be unpaid.
Other requirements: _________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Supervising Faculty Signature ________________________________________________
Student Intern Signature _____________________________________________
Date _____________