REQUEST TO TAKE AN INTERNSHIP
PLEASE FILL OUT THIS FORM COMPLETELY
Please check one:
Graduate/Post Baccalaureate Certification Student
Undergraduate Student
Enter semester/session and year in which you will be taking the course. ______________/____________/____________
Semester
Session
Year
The below named student has permission to take an Internship.
Is this a paid internship?
YES _______
NO _______
THIS FORM MUST BE TURNED IN WITH THE APPROPRIATE SIGNATURES BY THE STUDENT AT THE TIME HE/SHE
SELECTS COURSES FOR A GIVEN SEMESTER
____________________________/_____________________________________/________________________________
Last Name
First Name
Student ID Number
_______________________________________________/_______________________/____________/______________
Home Address
City
State
Zip Code
_____________________________________/_____________ Expected Date of Graduation ___________/___________
Student’s Signature
Date
Semester
Year
KU E-Mail Address ___________________________________ Telephone #_____________ Cell Phone #_____________
_______________/_________________________________________________________/______________/__________
Dept. & Course #
Course Title
Section
Credits
Please enter the course’s start, midterm and end date if different from those of the semester or session in which it is being taught:
______________
Start
______________
Midterm
______________
End
_______________________________________________/___________________________________________________
Sponsoring Organization
Organization’s Website Address/URL
_______________________________________________/___________________________________________________
Address
City, State, Zip Code
_______________________________________________/___________________________________________________
Industry
Organization’s Phone Number
INTERNSHIP: Signatures required for internships are the department chairperson, professor and that of the Dean of the appropriate
College. (Dean of appropriate College refers to the Dean of the College in which the course is taught. For Graduate students and Post
Baccalaureate Certification students, the signature of the Dean of Graduate Studies is also required.)
_________________________________/___________________________________________________/_____________
PRINT Professor’s Name
Professor’s Signature
Date
________________________________/____________/_______________________________________/_____________
Dept. Chairperson’s Signature
Date
Dean of College’s Signature
Date
________________________________/____________
Dean of Graduate Studies’ Signature
Date
DO NOT WRITE BELOW THIS LINE. OFFICE USE ONLY.
Date Entered __________________
Please add this course to the Schedule for the _____________________ Semester.
________________/__________________/___________________________/___________________________________
Course Prefix
Section
Credits
Professor’s Name
UNDERGRADUATE COURSES:
ANT
ART
BIO
BUS
CDE
CHM
CIS
CIS
CRJ
ELU
GEE
GEG
GEL
HIS
LIB
MAR
MAT
MUS
PED
PHY
POL
PSY
PSY
PSY
SOC
SWK
SWK
SWK
SWK
SPE
THE
TVR
WRI
WST
390, 391
392
390
390
394
390
280
380
390
338
390
394
390
390
375
390
280
391
340
390
390
305
362
363/364
390
381
382
383
384
390
390
390
390
390
Internships in Anthropology
Field Experience in Art
Internship in Biology
Internship in Business
Communication Design Internship
Internship in Chemistry
Internship in CIS I
Internship in CIS II
Criminal Justice Field Work
Internship in Early Childhood
General Studies Internship
Internship in Geography
Internship in Geology
History Internship
Field Work
Internship in Marine Science
Cooperative Internship in Mathematics
Field Experience in Music
Internship in Coaching Education
Internship in Physics
Federal, State or Local Government Internship
Practicum in Psychology
Internship in Industrial/Organizational Psychology
Clinical Internship in Psychology
Internship in Sociology
Field Instruction in Social Welfare I
Professional Seminar in Social Welfare I
Field Instruction in Social Welfare II
Professional Seminar in Social Welfare II
Speech Communication Internship
Internship in Theatre
Senior Internship in Electronic Media
Writing Internship
Internship in Women’s Studies
GRADUATE COURSES:
BUS
COU
COU
COU
COU
LIB
LIB
TVR
590
590
592
593
594
590
591
590
REVISED 5/09
Internship in Business
Supervised Counseling Experience
Field Experience I
Field Experience II
Field Experience IV
Field Work - School Library Media Centers
Field Work - Public & Special Libraries
Internship in Electronic Media
Please check the catalog,
online catalog and/or
Department for a current
list of Internships
available.