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Human Services Program
Department of Educational Leadership and Counseling
Darden College of Education
Old Dominion University
handbook
REQUEST FOR UP TO 100 HOURS
This form represents a request for up to 100 hours applied toward my Human Services 468 Internship course.
Submission of this form does not guarantee approval.
I ,_____________________________ (intern's name), am requesting that up to 100 hours be applied toward my HMSV 468 Internship, during________________ (semester, year) .
email address _______________________________________
student ID # _________________________________
Please fill in below the specific details of your previous experience and how that experience is applicable toward your current enrollment. A maximum of 100 hours may be applied; this approval is subject to evaluation by the program coordinator.
REASON FOR REQUEST:
please check one:
_____ Associate's degree in related field (please provide an official transcript showing the awarded degree)
_____ Previous Internship experience
_____ Previous work experience
_____ Other
All applicants who do NOT have an associates degree in a related field must have at least one year of experience in a human service agency to be considered for a possible reduction in internship hours. The following documentation will need to be submitted for consideration:
A cover letter explaining your request
An expanded resume detailing your work history, duties, etc.
Documentation in the form of a letter from your former supervisor on agency letterhead.
An official job description
A learning essay detailing your experiences, activities, what you have learned through them, etc This essay should be typed, double-spaced, and at least 300 words.
A copy of your "lesson plans" for any groups conducted.
All information must be forwarded to the program coordinator when applying for internship:
HS TELETECHNET Internship Coordinator
Room ED 110, ELC Department
Old Dominion University
Norfolk, VA 23529-0157
Late submissions will not be accepted. Do not fax materials.
Student Signature ____________________________________________
TELETECHNET Location____________________________________________
Date_________________________________________________
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