Please fill out the top half of this form. Write brief descriptions of the nature of the work you will be performing at your internship, obtain the necessary signatures and file with the Graduate Director no later than one week from the first day of your internship. Failure to do so will result in your being administratively dropped from the course or having your grade reduced one letter grade for each week (or portion of a week) the form is late.

Student Name: ______________________________________________________________________

Beginning Date of Internship: ____________

Ending Date of Internship: _______________

Mailing address during internship: ________________________________________________________

(Street) (City) (State) (Zip)

Phone #'s during internship: _____________________________________________________________

(Home) (Work)

Internship Supervisor: __________________________________________________________________

(Name) (Title)

Internship Agency: ____________________________________________________________________

Mailing Address (Agency): ______________________________________________________________

(Street) (City) (State) (Zip)

Signatures/Dates

STUDENT:___________________________________________________________________________

INTERNSHIP SUPERVISOR:____________________________________________________________

GRADUATE DIRECTOR:______________________________________________________________