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LA 495 (HISTORY)-----INTERNSHIP COURSE

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STUDENT INFORMATION FORM

--please fill out this information form and send back to (either a completed hard copy (via regular mail) or, preferably, completed Word document (via attachment)

STUDENT DATA

Name:

Date:

Student ID#: Major:

Penn State email address:

Local telephone (cell phone #):

Semester standing:

INTERNSHIP SITE DATA

NAME OF INTERNSHIP (if appropriate; leave blank otherwise):

Semester of internship:

Internship begins:

Internship ends:

Number of hours ("site time") a week:

"ON SITE" INTERNSHIP SUPERVISOR INFORMATION

Name of institution:

Name of "on site" internship supervisor:

Title:

Office address:

"On site" supervisor's telephone number:

Email address:

ACADEMIC SUPERVISOR FOR YOUR INTERNSHIP

(person must be PSU History Dept. faculty member)

Name of History faculty member, who has agreed to serve as your academic supervisor:

Academic supervisor's telephone number:

Email address:

HOW CAN YOU BE CONTACTED DURING YOUR INTERNSHIP?

Mailing address:

Residence telephone (cell phone #):

Email address: