University of Northern Iowa
Postsecondary Education: Student Affairs
Internship Registration Form
This form must be completed prior to registration for each internship and must be returned prior
to beginning the practicum or internship:
Student’s Name:_______________________________ ID#:_________________________
Address:___________________________________________________________________
City:________________________________________ Zip:__________________________
Student Email_________________________
Student Phone:(____) _________________
Field Supervisor’s Name:______________________________________________________
Placement Site:______________________________________________________________
Site Address:________________________________________________________________
City:________________________________________ Zip:__________________________
Field Supervisor Email
Field Supervisor Phone: (____)_________________
Internship Start Date______________
Internship End Date
Approved by Field Supervisor (date) __________________________________