Office of the Registrar

Experiential Learning Opportunity Contract for
INTERNSHIPS, PRACTICA AND JOB SHADOWING

This form must be completed prior to beginning the experience

Name                            ID#  

Phone #                                                     Classification during study:

Major(s)                  Minor(s)
 

Section A - COURSE INFORMATION
To be filled out completely by the student and sponsoring faculty member

Credit in department.                       Semester                          Year

PRACTICUM: credits. Course #           INTERNSHIP: credits. Course #

JOB SHADOW: credits. Course #           NO CREDIT:
Note: at least 40=60 hours of supervised work experience is required per credit.

Academic Advisor or Supervising Professor: Ext.

Please note: Regular tuition rates apply to internships and practicum experiences. The Registrar's Office will register you for this internship/practicum experience upon receipt of this completed form. All experiences are graded on a Satisfactory/Unsatisfactory basis.
 

Section B - CRITERIA FOR ACADEMIC EVALUATION
To be filled out by student in consultation with a faculty member or academic advisor

Department criteria:
Log of daily experiences Copies of reports of projects assigned Follow-up periodic visits
Final oral debriefing          Other:

Learning Objectives: What do you want to learn from this experience?

 

Section C - APPROVAL SIGNATURES
All signatures from faculty advisor, supervising professor and academic dean must be obtained before bringing this form to the Enterprise Resource Center.

1. Academic Advisor        ___________________________________________ Date ___/___/___

2. Supervising Professor  ___________________________________________ Date ___/___/___

3. Student                        ___________________________________________ Date ___/___/___

 

Section D - INTERNSHIP/PRACTICUM INFORMATION & RESPONSIBILITIES
To be filled out by the Enterprise Resource Center for placement in experiential learning engagement

Company/Organization/Dept:
Direct Supervisor: Title:
Address: Phone:
City: Fax:    
State:         Zip:
Email: Duration of experience: From to


Work and Assignments (day-to-day or project plans):

How will the supervisor assist the intern/practicum student?

How will the supervisor monitor the intern's progress?

Intern can work hours per week, or a total of hours.

Enterprise Resource Center ________________________________________ Date ___/___/___. Ac4ademic

Academic Dean                 ___________________________________________ Date ___/___/___
 

Copy Distribution

 Registrar Student Academic Advisor Professor

Organization

 Division Chair Career Development Dir. of E.R.C.

8/17/2004

Please print out the completed form, sign it and return it to:

Office of the Registrar
Huntington University
2303 College Avenue
Huntington, IN 46750
Fax (260) 359-4086
Contact Us   |   2303 College Avenue  Huntington, IN 46750   |   260.356.6000   |   Copyright 2004