Health Promotion and Physical Education (HPPE)
PETITION FORM
ALL INFORMATION MUST BE TYPED
Part A: STUDENT INFORMATION
Are you attending Ithaca College on an International Student Visa?
Is this site within a 500 mile radius of Ithaca College?
When you complete this experience will you be registering as a Washington Campus Student?
Name:
ID#:
NO
NO
NO
E-mail:
Local
Address:
Permanent
Address:
Local Phone:
Permanent
Phone:
Major:
YES
YES
YES
Academic Advisor:
Total credits earned to date:
Minor/Concentration:
GPA:
Class Status:
Part B: FACILITY/SITE INFORMATION
Name of Facility:
Site Supervisor Information
Facility Address:
Street
City, State, Zip
Name:
Title:
Phone #:
_______
Fax Number:
E-mail:
Is this internship site within a 500 mile radius of Ithaca College?
Start Date:
YES
NO
Completion Date:
Part C: COURSE INFORMATION
For HLTH Fieldwork will need to consult with Jules Boles, Internship Coordinator before filling out the information in
this section. For PHED Fieldwork, you will need to consult with Andy Byrne.
Ithaca College Faculty
Supervisor:
Course you plan to be registered in:
Number of Credits:
(.5 – 12)
Julie Boles
Other (specify)
Andy Byrne
_______
HLTH-34900 Fieldwork in Health (.5 – 6 credits)
PHED-34900 Fieldwork in Physical Education (.5 - 6 credits)
HLTH-44900 Internship in Health (6 – 12 credits)
Other (specify course # and title)
Course Number:
Course Title:
Semester of registration:
(choose one)
Fall
Winter
Spring
Summer
HPPE Petition Form
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Part D: Design Statement
(all information must be typed)
Career Goals:
Learning Objectives:
Location:
Dates:
Hours per week:
Description of the Agency:
Student Preparation for Experience:
Nature and Scope of Study:
Interaction with Faculty Supervisor:
Grading System:
Part E: STUDENT SIGNATURE (student must sign and date in ink)
I give the Internship Coordinator permission to discuss my academic performance and professional
behavior with the site supervisor(s). Also, my signature indicates agreement to and responsibility for
fulfilling all course, department, and site requirements pertaining to this fieldwork/internship experience.
_______________________________________________
Student Signature
_____________
Date
When complete, students need to obtain the appropriate signatures from the IC faculty. Once all faculty
signatures have been obtained, this form should be given to the Office of Experiential Learning in Room 313
located in Smiddy Hall.
HPPE Fieldwork Petition Form
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Part F: APPROVAL SIGNATURES
Internship Coordinator
Date
Academic Advisor
Date
Department Chair
Date
Office of Experiential Learning
Date
HSHP Dean’s Office
Date
HPPE Fieldwork Petition Form
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