Form A: INTERNSHIP COURSE APPLICATION

Semester you plan to do internship:     Summer    Fall     Spring        Year:  _______________

Name:____________________________________________________________ UIN#:_____________________________________

Email Address: ___________________________________________________

Local Address:_______________________________________________________________

City: ______________________________ Zip: __________________

Local Phone: _______-____________Do you expect this to change prior to internship?   Yes    No

Cell Phone (if any): _______ - __________________

Next of Kin: ________________________________________________________________

Parent/Spouse Address:_______________________________________

City: ______________________________State: __________ Zip: ____________

Parent/Spouse Phone: (_________)_________-____________

Where do you anticipate living during the few weeks prior to your internship?       Locally        Parent/Spouse       Other         (If you marked "other," please list this address at the bottom of this form)

Do you have an internship position already?  Yes or No

If  "Yes":      Organization:__________________________________________________________________________

Address:_______________________________________________________________________________________

City: _________________________________  State:____________________  Zip: __________________

Supervisor's name ( if known) _______________________________________________________________________

Email Address: _________________________________________________________________________

Phone:____________________________ Starting Date  ___________________Termination Date_____________

1) ______________________________ 2) ______________________________

(Note:  Faculty normally only supervise students working in their area of expertise; some faculty members are unavailable for intern supervision during a given semester.)

Credit Hrs Completed (by start of internship): ________ Current GPR: ________ 

RPTS Hrs Completed (by start of internship): ________ RPTS GPR: _______