STUDENT

Name:                                                                                                                                                                                                 

Address:                                                                                                                                                                                              

                                (Street)                                                   (City)                                  (State)                    (Zip)

Phone:                                                                                    Major:                                                                                               

WSU ID#                                                                               Anticipated Graduation Date:                                                       

E-Mail Address:                                                                   WSU Credits Earned                                   GPA:                          

Identify and establish due dates for professional development or classroom application activities to

be accomplished during the internship. Describe how learning goals will be assessed.

FIELD SUPERVISOR

Name:                                                                             Phone:                                                                                               

Company or Agency:                                                                                                                                                             

Address:                                                                                                                                                                                   

                        (Street)                                                   (City)                                  (State)                    (Zip)

E-Mail Address:                                                                                                                                                                      

Start Date:                                                                                 Closing Date:                                                                       

Internship Title:                                                                       Expected Hours Per Week                                                 

Brief Description of Job/Tasks to be Accomplished:                                                                                                       

FACULTY SPONSOR

Name:                                                                                         Phone:                                                                                 

Course Number:                                                                       Semester/Credits:                                                              

SIGNATURES

Student:                                                                                                         Date:                                                              

Faculty Sponsor:                                                                                          Date:                                                              

Field Supervisor:                                                                                          Date: