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College of Humanities and Social Sciences Internship Approval Form | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10
Special Instructions:  Students, together with faculty members supervising internships or co-ops, MUST initiate this application and have it
processed through the approvals outlined in Section III below, as early as possible.
DEADLINES: | FALL -- 1st Monday in July |  |  |  | SPRING -- 2nd Monday in November |  |  |  |  | SUMMER -- 2nd Monday in April
Student Requirements:  An undergraduate student must have earned at least 57 credits, have a minimum GPA of 2.0 and meet departmental internship requirements.
A graduate student must have earned at least 12 graduate credits, have a minimum of 3.0 GPA and meet departmental internship guidelines. (See the Undergraduate or
Graduate catalog for details.)
I.  Educational Data:  (To be Completed by Student)  PLEASE TYPE
Name: |  |  |  |  |  |  |  | [NAME] ID: | @
 | Last Name |  | First Name |  | M.I.
 |  |  |  |  |  |  |  | University
Home Address: |  |  |  |  |  |  |  | Address:
 | Street |  |  |  |  |  |  |  | Street
City |  |  | State |  | Zip |  |  | City | State | Zip
 |  |  |  | University |  |  |  | E-Mail
Home Phone: |  |  |  | Phone: |  |  |  | Address:
Check One: |  | Graduate |  | Undergraduate |  | Major: |  |  | Minor:
Overall  QPA: |  | Major  QPA: |  | Total Earned Hrs: |  | Anticipated Graduation Date:
Advisor: |  |  |  |  |  | Department:
II.  Internship Data:  (To be completed by student and faculty advisor)    Check Type of Experience
 | Internship |  |  | L.O.R.L.* |  | Student Teaching* |  |  | T.H.I.S.* | _____     The Washington Center *
 | Capital Semester* |  |  | White House* |  |  | Co-op
*Indicates additional form needs to be completed - consult with advisor
Semester & Year of Internship |  |  |  |  |  |  | Total Credits Scheduled for Semester (including Internship)
Internship # of Credits |  | Dept. |  | Course No. |  | Section |  | Course Title
Other Courses # of Credits |  | Dept. |  | Course No. |  | Section |  | Course Title
 |  | Dept. |  | Course No. |  | Section |  | Course Title
 |  | Dept. |  | Course No. |  | Section |  | Course Title
Company/Agency |  |  |  |  |  |  | Starts: | / | /
 |  |  |  |  |  |  |  | Month | Day | Year
Department |  |  |  |  |  |  | Ends: | / | /
 |  |  |  |  |  |  |  | Month | Day | Year
Address |  |  |  |  |  |  | No. of Weeks |  | Hrs. Per Week
 |  |  |  |  |  |  | Daily   From |  | To
On-Site Supervisor's Name |  |  |  |  |  |  | Paid |  | Nonpaid
 |  | Please Print
Student Address |  |  |  |  |  |  | Student's Phone
During Experience |  |  |  |  |  |  | During Experience |  | (         )
 |  |  |  |  |  |  | Internship Site Phone:  (         )
III.  Internship/Co-op Approval (The following signatures MUST be obtained in sequence)
Please Read:  A typed one to three page description of the internship job/co-op duties to be undertaken must be attached before submitting this form for approval.
This form will not register you for your internship.  You MUST meet with your department [NAME] to receive instructions on how to register.  IUP does NOT
provide liability coverage for students.  The student's signature indicates they have read and understand that IUP does not provide liability coverage for students.
 |  |  |  |  |  |  |  | Date
Student's Signature
 |  |  |  |  |  |  |  | Office
 |  |  |  |  |  |  |  | Phone:
Print or Type Faculty Supervisor Name
 |  |  |  |  |  |  |  | Date
Department Coordinator Signature
 |  |  |  |  |  |  |  | Date
Chairperson
 |  |  |  |  |  |  |  | Date
[NAME]
NOTE:  All intern/co-op students are required to complete a minimum of 40 work hours per 1 academic credit. |  |  |  |  |  |  |  |  |  | YAA:dlw Rev 9/10