Peru State College Graduate - Internship & Permit to Register
Peru State College Graduate - Internship & Permit to Register
This form is to be completed by a Graduate student seeking a graduate-level internship.
Date
Date
/
MM
/
DD
YYYY
Student Name
Student Name
*
First
Last
Student Phone
Student Phone
*
-
###
-
###
####
Student Email
*
PSC Academic Program
*
PSC Academic Program
M.S. Education - Curriculum & Instruction
M.S. Organizational Management
Year seeking graduate internship
*
Semester seeking graduate internship
*
Semester seeking graduate internship
Fall
Spring
Summer
Are you eligible to work in the United States?
*
Are you eligible to work in the United States?
Yes
No
Credit hours you wish to complete within the semester above of this Graduate Internship?
*
Credit hours you wish to complete within the semester above of this Graduate Internship?
3 credits - working 135 hours
6 credits - working 270 hours
Please check the box next to each item to indicate your understanding of the item.
*
Please check the box next to each item to indicate your understanding of the item.
I have read the Graduate Internship Guidelines and agree to comply with the internship requirements,
https://graduate.peru.edu/_documents/21Guidelines_for_Completing_a_Graduate_Internship.pdf
I have discussed this internship opportunity with the Graduate Programs Office and determined the number of credit hours to complete my internship.
I have previously enrolled for internship credit.
*
I have previously enrolled for internship credit.
Yes
No
I have completed or will also be enrolled for EDUC/MGMT 601 or EDUC/MGMT 602, summer enrollment).
*
I have completed or will also be enrolled for EDUC/MGMT 601 or EDUC/MGMT 602, summer enrollment).
Yes
No
Organization of internship site (Organization name, city, state)
*
Organization Employer/Supervisor Name
Organization Employer/Supervisor Name
*
First
Last
Employer/Supervisor Email
*
Employer/Supervisor Phone
Employer/Supervisor Phone
*
-
###
-
###
####
Upload your Internship Learning Objective/Training Agreement form.
You must have all required signatures on this form before submission.
Attach Files
I understand that any false information on this or any other internship-related forms will be sufficient reason for rejection or termination of my graduate internship, and I will receive a grade of 'F' for this internship. I herewith authorize and request PSC to communication with my internship site supervisor regarding my performance and herewith hold such persons harmless for giving any and all information within their knowledge of records. It is the responsibility of the student intern to meet the requirements of the Graduate Programs Internship in a timely manner and within the semester enrolled. Failure to do so may result in termination of the internship or assignment of grade of 'F'.
Student signature
Draw your signature into the box below.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.