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 Page 1 of 3 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 Page 2 of 3 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 Page 3 of 3