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Old Dominion University Internship Placement  
 
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HUMAN SERVICES PROGRAM
Educational Leadership and Counseling
Old Dominion University

INTERNSHIP PLACEMENT

This form is to be completed by the intern and submitted to the internship instructor by the second seminar meeting. Failure to return this signed form may result in the removal of the student from the internship for that semester. The student may reapply for internship at a later date.


Student: __________________________ Student UIN _____________________________
Student Address: ____________________________________________________________
___________________________________________________________________________
Telephone: (home) __________________________ (work) ___________________________
Placement site: _________________________________________________________________
Complete Address of Placement Site: _______________________________________________
______________________________________________________________________________
Placement Site Telephone: ________________________________________________________
On-Site Supervisor: _____________________________________________________________
Position: ______________________________________________________________________
Starting Date: ____________________________
Internship Schedule:

    Monday Time: ________________________________
    Tuesday Time: ________________________________
    Wednesday Time: ________________________________
    Thursday Time: ________________________________
    Friday Time:________________________________ 
    Saturday Time: ________________________________
    Sunday Time: ________________________________

    Below, please list each course objective and explain what activities will take place during internship to ensure that the objective will be met: (Please attach additional paper as necessary)


























    I,_______________________________ (On-Site Supervisor) agree with the information provided above. My signature below indicates I have received the Internship On-Site Supervisor Handbook and agree to participate according to the guidelines therein.

    ___________________________________________
    On-Site Supervisor Signature

    Please provide clear and complete directions to the Internship Site on the reverse side of this form.
  
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This page was last modified: Wed, 18 May 2005 06:37 PM EST 		    tcollier@odu.edu