Internship Course Application IPL 300

Internship Course Application – IPL 300

1. The student should complete this form AFTER accepting an internship offer. This form is to be completed for an academic, credit bearing, internship. (The same process applies for online students.) 2. Once completed, the student should have the field supervisor (supervisor at the internship site) sign on page 4. 3. Once the field supervisor has signed, the student should obtain department approval with a signature on page 4. 4. Submit the completed form to IPL in Brookens 482 or [email protected] by the first week of the semester; upon approval, the student will receive an email regarding course approval to register for the internship course, IPL 300. . Accounting students will be given course approval for an on-campus section unless an online request is granted by the ACC department. . All other students will be given course approval for an online section unless an on-ground request is granted by the IPL office.

Internship Semester/Year: ☐ Spring 20____ ☐ Summer 20____ ☐ Fall 20____ STUDENT INFORMATION Student Name: ______University ID Number: ______Phone: ______UIS Email Address: ______Academic Program/Major: ______Academic Advisor: ______

Expected Graduation Date: ______☐Are you an international student? ☐ Are you receiving military benefits?

PLACEMENT INFORMATION Placement: ______

Address: ______City: ______State: ____ Zip Code: ______Country: ______Field Supervisor's Name: ______Title: ______

Phone:______E-Mail: ______

Is this internship ☐ PAID ☐ UNPAID?

Fifty (50) hours of work must be completed for each credit. Total semester credit hours: ______x 50 = ______Minimum number of hours to be worked All internships must be at least 8 weeks in length. Fifteen (15) weeks is average for fall and spring semesters. Beginning Date: ______Ending Date: ______Average number of hours per week: ______How will you use this credit (consult with your advisor if needed)? ECCE Engagement or ECCE Elective? Number of Credits ______General Electives? Number of Credits ______1 University Requirement (pre-2007 catalog)? Number of Credits ______

2 1. Describe, in detail, the proposed internship OR attach a detailed job description as provided by the placement. List specific duties or tasks you will complete.

2. Is this internship being done at your current employment? ☐ Yes ☐ No If yes, define how your internship significantly differs from your previous/regular duties.

How many hours each week will be devoted to the new experiences? ______

3. What do you want to accomplish and learn from this proposed internship? Briefly, list at least 5 or 6 objectives. These are tentative objectives. Later in the semester, you will develop a Learning Contract incorporating more detail. Consider that you might explore or confirm career choices, understand the value of diversity, identify social concern issues, develop and apply leadership skills, learn new transferrable skills, apply your academic knowledge.

4. What academic coursework, experiences, and/or skills do you have that will be an asset in your proposed internship?

3 STUDENT SIGNATURE

As a currently enrolled UIS student and by signing this contract, I understand (PLEASE INITIAL EACH STATEMENT):

In order to earn academic credit I must:

______Participate in the internship seminar classes (online or on-ground) held during the semester. ______Stay up to date on assignments based on due dates I set at the beginning of the semester. ______Keep a reflective journal of every day I work at the internship. Hours not recorded in the journal do not count towards my total. ______Schedule and participate in a site visit with the Field Supervisor and UIS Supervisor. ______Contact my course instructor immediately if I start to fall behind or have questions. ______If completing an internship for more than 6 credit hours, I must complete additional course requirements.

During my internship, and as an ethical representative of UIS, I will:

______Dress appropriately for the workplace, as defined by the employer’s dress code. ______Demonstrate respect, dependability, and cooperation with my supervisor and co-workers. ______Ask questions to identify/clarify any confusion regarding my internship responsibilities. ______Maintain a strictly professional relationship with my supervisor and co-workers. ______Refrain from the consumption of alcohol and/or drugs while performing the duties of my internship. ______Adhere to organizational policies, including confidentiality of personnel, projects, and research. ______Strive to understand what constitutes a permissible work absence and who to notify if absent. ______Report changes in schedule, supervision, or problems with my internship to my instructor and/or UIS supervisor. ______Adhere to all UIS policies and procedures, including the student code.

______RELEASE: In consideration of being permitted to participate in the above-noted placement as an internship (AST), in full recognition and appreciation of the dangers inherent in participation in said placement and related activities, do hereby agree to assume all risks and responsibilities surrounding participation in the above-noted placement and activities undertaken as an adjunct thereto; and further, I do for myself, my legal representatives, my heirs and assigns, agree to defend, hold harmless and indemnify, and hereby release and forever discharge the Board of Trustees of the University of Illinois and the University of Illinois at Springfield, their officers, agents and employees, from any and all claims, demands, actions or causes of action arising from or by reason of any bodily injury or personal injury, known or unknown, death or damage to personal property resulting from any accident which may occur as a result of participation in said placement and activities adjunct thereto, whether by negligence or not. Further I state that I have carefully read this Release and know and understand its contents and sign this Release as my own free and voluntary act.

______International Students only: As an international student, I must be approved for Curricular Practical Training (CPT) by the ISS office at UIS prior to beginning the internship experience. I must also submit the employer’s offer letter, which states expected work load (number of hours per week not to exceed 20 per week during regular semesters and 40 hours per week during summers) and start and end dates to the ISS office and Internship office. I am only allowed to participate in a maximum of two internship experiences, and only under extraordinary circumstances. Thus, only two CPT authorizations, which cannot total one year of full time CPT.

I have fully read, understand, and agree to all of the above statements:

STUDENT SIGNATURE:______DATE:______4 5 Printed Name: ______FIELD (ON-SITE) SUPERVISOR APPROVAL As an Internship Field Supervisor for a UIS Student, I understand (PLEASE INITIAL EACH STATEMENT):

______I have reviewed students’ qualifications, selected an intern, and assigned projects in accordance with federal, state, and local laws (e.g., race, sex, national origin, religion, age, disability, etc.).

______I agree to act as (or appoint) a Field Supervisor responsible for supervision, mentorship and activities of the intern while on-site. I also agree to discuss the intern’s work with the intern and to provide feedback and suggestions as necessary.

______I will provide meaningful work of educational value in the project areas for which the internship is designed. Basic clerical responsibilities will not exceed 20% of the intern’s time.

______I agree to report any changes, concerns, or questions I may have regarding the intern or internship experience directly to the Internships and Prior Learning Services Office.

______I agree that my relationship with the intern will remain professional at all times.

______I agree to provide performance feedback to my intern throughout the internship experience.

______I will participate in a site visit or phone conference with the student and the student’s UIS supervisor about halfway through the internship.

______I should complete a Field Supervisor Evaluation near the end of the academic semester for which my intern is registered (UIS does not expect disclosure of proprietary company information).

______Neither a relative of the student nor a current UIS student can serve as supervisor without prior approval by the Internship Coordinator.

REQUIRED SIGNATURE. I have fully read, understand, and agree to all of the above statements:

Printed Name: ______Signature:______Date:______

UIS DEPARTMENT/SUPERVISOR APPROVAL

The STUDENT must have a faculty member* in his/her department endorse this internship. *Students in the following degree programs should have the faculty member listed approve/sign this form. Accounting: Dr. Leonard Branson ([email protected]) Business Administration (Management, Marketing, Sports Management) and Economics: Dr. Dyanne Ferk ([email protected]) Computer Science: Dr. Ted Mims ([email protected]) Management Information Systems: Dr. Rassule Hadidi ([email protected]) Psychology: Dr. Sheryl Reminger ([email protected]) Other departments: Identify your faculty advisor or a faculty member with whom you have taken courses or worked.

DEPARTMENT SIGNATURE I agree that this student should complete the internship, as presented on his/her internship application, for his/her degree progress.

Printed Name: ______Signature:______Date:______

Please indicate whether or not you agree to be the UIS supervisor for this student's experience♦: ____ YES _____ NO 6 ♦The Computer Science and CCJ Departments will assign a UIS supervisor.

The UIS Supervisor has three duties: 1. To make one “site visit” (can be a conference call). The student is responsible for scheduling the site visit at a time convenient for all. This should be done when no more than 40 to 50 percent of the clock hours have been completed. 2. To review and endorse the student's Learning Contract at or immediately after the time of the site visit. 3. To review and assess the completed internship materials and recommend awarding credit (or not).