Name:____________________________ Student ID #____________________________

Address: _________________________________________________________________________________
Complete Street Address

_________________________________________________________________________________
City/State/Zip

Home or cell telephone:______________________

Internship Semester and year:
Fall _____
Spring _____
Summer _____

e-mail address:_____________________________

Have you declared your major in HMSV? YES NO (IF NOT YOU MUST DO SO IN EDUCATION 152)

Preferred Type of Agency:____________________________________________________________________
(If you are planning an internship in a school setting, you MUST complete the "Request Placement in a School" form, the specific school system application form, if applicable, and submit them with this application.)

Indicate your grades in the course you have completed. IF YOU HAVE NOT YET COMPLETED A REQUIRED COURSE, INDICATE WHEN YOU WILL HAVE COMPLETED THE COURSE(S). ATTACH YOUR OLD DOMINION TRANSCRIPT.

_____ COUN/HMSV 339 Interpersonal Relationship
_____ COUN/HMSV 341 Introduction to Human Services
_____ COUN/HMSV 342 Research Methods in Human Services 
_____ COUN/HMSV 343 Human Services Methods
_____ COUN/HMSV 344 Career Development and Appraisal
_____ COUN/HMSV 345 Evaluation Methods in Human Services
OR
_____ HMSV 440 Program Development, Implementation, & Funding
_____ COUN/HMSV 346 Diversity Issues in Human Services
_____ HMSV 368 Field Observation in Human Services
_____ COUN/HMSV 444 Psychoeducational Groups
_____ COUN/HMSV 491 Family Guidance
_____ COUN/HMSV 447 Seminar in Alcoholism Counseling
 OR
_____ COUN/HMSV 448 Intervention & Advocacy with Children

*REMINDER: A GPA of 2.0 or better must be earned in COUN/HMSV 339, 341, 343, and 368 before taking COUN/HMSV 468.

* Students are also required to submit,a current resume and a two-page letter briefly addressing their (1) development of interest in human services, (2) areas of interest for internship, (3) personal strengths and growth areas, and (4) life experiences which have affected their development as a human services professional. Theses items must be included with your applicaiotn in order the applicaiton to be considered complete.Submissions that do not demonstrate college-level grammatical and writing conventions will be refused.

_______________________________________________________________
Signature/Date

Approved by: ___________________________________________________
Signature Date

NOTE: You will be notified of your approval by e-mail to your ODU student account. That e-mail will provide information on the date, time, and place of the mandatory internship orientation meeting.