Health Promotion and Physical Education (HPPE)

INTERNSHIP PETITION FORM

ALL INFORMATION MUST BE TYPED

Part A: STUDENT INFORMATION

Name: / ID#: / E-mail: @ithaca.edu
Local Address: / Permanent Address:
Local Phone: / Permanent Phone:
Major: / Total credits earned to date:
Minor: / Credits currently enrolled in:
Projected Graduation Date (month, year):
Academic Advisor:
Are you attending IthacaCollege on an International Student Visa? YES NO
When you complete this experience will you be registering as a Washington Campus Student? YES NO

Part B: COURSE INFORMATION

You will need to consult with Jules Boles, Internship Coordinator before filling out the information in this section.

IthacaCollege Faculty Supervisor:

/

Julie Boles

Other (specify)

Course you plan to be registered in / HPS-39000 Internship in Health Policy Studies
HLTH-44900 Internship in Health
Other (specify course # and title)
Course Number:
Course Title:
Number of Credits:
Internship 6-12 credits / Semester of registration:
(choose one) / Fall Spring
WinterSummer

Estimated Time Allotments++

+ / =
WORK HOURS
Hours of work at site / RELATED HOURS
Hours of related study and/or faculty consultation / TOTAL HOURS
Students must complete
60 hours per credit

++ Since this is a work placement, students are given credit on the basis of the work they do.

Thus, commuting hours to and from the work site can not be included in the overall tally of hours.

Part C: FACILITY/SITE INFORMATION

Name of Facility: / Site Supervisor Information
Facility Address:
Street
City, State, Zip / Name:
Title:
Phone #:
Fax Number:
E-mail:
Is this internship site within a 500 mile radius of IthacaCollege? YES NO
Start Date: / Completion Date:

Part D: Design Statement

(all information must be typed)

Career Goals:

Learning Objectives:

Location:

Dates: / Hours per week:

Description of the Agency:

Student Preparation for Experience:

Nature and Scope of Study:

Interaction with Faculty Supervisor:

Grading System:

Part E: STUDENT SIGNATURE (student must sign and date in ink)

I give the Internship Coordinator permission to discuss my academic performance and professional behavior with the site supervisor(s). Also, my signature indicates agreement to and responsibility for fulfilling all course, department, and site requirements pertaining to this fieldwork/internship experience.

______

/

______

Student Signature

/

Date

When complete, students need to obtain the appropriate signatures from the IC faculty. Once all faculty signatures have been obtained, this form should be given to the Office of Experiential Learning in Room 322B located in Smiddy Hall.

Part F: APPROVAL SIGNATURES

Julie Boles, Internship Coordinator / Date
Academic Advisor / Date
Department Chair / Date
Office of Experiential Learning / Date
HSHP Dean’s Office / Date

HPPEInternship Petition Form

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