Health Promotion and Physical Education (HPPE)
INTERNSHIP PETITION FORM
ALL INFORMATION MUST BE TYPED
Part A: STUDENT INFORMATION
Name:
ID#:
E-mail:
Local
Address:
Permanent
Address:
Local Phone:
Permanent
Phone:
@ithaca.edu
_______
Major:
Total credits earned to date:
Minor:
Credits currently enrolled in:
Projected Graduation Date (month, year):
Academic Advisor:
Are you attending Ithaca College on an International Student Visa?
YES
NO
When you complete this experience will you be registering as a Washington Campus Student?
YES
NO
Part B: COURSE INFORMATION
You will need to consult with Jules Boles, Internship Coordinator before filling out the information in this section.
Julie Boles
Other (specify)
Ithaca College Faculty
Supervisor:
HPS -39000 Internship in Health Policy Studies
HLTH-44900 Internship in Health
Other (specify course # and title)
Course Number:
Course Title:
Course you plan to be registered in
Number of Credits:
_______
Semester of registration:
Internship 6-12 credits
Fall
Winter
(choose one)
Spring
Summer
Estimated Time Allotments++
+
=
WORK HOURS
RELATED HOURS
TOTAL HOURS
Hours of work at site
Hours of related study and/or
faculty consultation
Students must complete
60 hours per credit
++
Since this is a work placement, students are given credit on the basis of the work they do.
Thus, commuting hours to and from the work site can not be included in the overall tally of hours.
Part C: 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:
HPPE Internship 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:
HPPE Internship Petition Form
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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 322B
located in Smiddy Hall.
Part F: APPROVAL SIGNATURES
Julie Boles, Internship Coordinator
Date
Academic Advisor
Date
Department Chair
Date
Office of Experiential Learning
Date
HSHP Dean’s Office
Date
HPPE Internship Petition Form
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