Internship Course Application – EXL/IPL 300
For IPL Office Use
DATE RECEIVED:
1. The student should complete this form AFTER accepting an internship
offer. This form is to be completed for an academic, credit bearing,
COURSE:
internship. (The same process applies for online students.)
2. Once completed, the student should have the field supervisor (supervisor
CRN:
at the internship site) sign on page 4.
3. Once the field supervisor has signed, the student should obtain
UIS SUPERVISOR:
department approval with a signature on page 4.
4. Business Administration students should complete page 5.
APPROVAL:
5. Submit the completed form to IPL in Brookens 482 or internship@uis.edu;
upon approval, the student will receive an email regarding course approval
to register for the internship course, EXL/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:
Phone:
___
__
Is this internship
☐ PAID
Title:
___
E-Mail: __
___
☐ UNPAID?
Fifty (50) hours of work must be completed for each credit.
Total semester credit hours: ________
x
50 = _________ Total 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:
_____
Proposed number of weeks: _________
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 ______
University Requirement (pre-2007 catalog)?
Number of Credits ______
University of Illinois Springfield
Internships and Prior Learning Services IPL
One University Plaza MS BRK 482 • Springfield, IL 62703-5407
217-206-6640 • Fax: 217-206-7415
ipl@uis.edu • www.uis.edu/ipl/
1. Describe, in detail, the proposed internship OR attach a detailed job description as provided by the placement.
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?
BUSINESS ADMINISTRATION STUDENTS: DON’T FORGET TO COMPLETE PAGE 5.
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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 UIS supervisor.
______ 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:___________________
Printed Name: ____________________________________________
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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 without regard to age, race, gender, national
origin, religion, disability, color, or marital status.
______ I agree to act as (or appoint) a Field Supervisor responsible for supervision, mentorship and activities of the intern while onsite. 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
administrative 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(s) will remain professional at all times.
______ I agree to provide performance feedback to my intern(s) 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 understand I need to complete a Field Supervisor Evaluation near the end of the academic semester for which my intern(s)
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
Business Administration (Management, Marketing, Sports Management): Dr. Dyanne Ferk
Economics: Dr. Dyanne Ferk
Management Information Systems: Dr. Rassule Hadidi
Psychology: Dr. Sheryl Reminger
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
♦
Does not apply to Computer Science or Criminal Justice department.
_____ NO
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 endorse awarding the credit (or not).
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Business Administration students only.
All others can skip this page and do not need to print it.
Have you completed the following preparation requirements?
Utilized OptimalResume (through Career Connect):
Resume: ______
Letter Builder: _____
Interview Skills: ______
Watched the required Career Spot videos? ________
(Information on these requirements found in the Business Students Preparation Requirements document on the internship website)
Please rate the usefulness of each preparation tool (Optimal & Career Spot):
Tool
Very Useful
Somewhat Useful
Not Useful At All
Resume
Letter Builder
Interview Skills
Career Spot Videos
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