Application for Internship in
Sociology, Gerontology and Sociology for Nonprofit Leadership
Information provided will be used to determine eligibility for the Internships for Sociology, Gerontology,
Nonprofit Leadership. Submit one copy to the faculty supervisor and one to the field supervisor. Please
respond to all items.
Name: _____________________________________________
Tech ID # _______________________________
Date________________________
Phone: ___________________________
Campus Email: ____________________________________________________________________
Local Address: _____________________________________________________________________
(Street Address, Apt. #)
_____________________________________________________________________
(City)
(State)
(Zip)
Permanent Address: ________________________________________________________________
(Street Address, Apt. #)
______________________________________________________________
(City)
(State)
(Zip)
In case of an emergency, notify ______________________________________________________
Relationship: _____________________________ Phone: _________________________________
Undergraduate Student ______
or
Graduate Student _______
Major(s): _______________________________________________________________________
Minor(s): _______________________________________________________________________
Certificate(s): ___________________________________________________________________
Cumulative GPA: _______________
Projected Graduation Date: ____________________
Desired term(s) for placement: Fall _________ (Yr) Spring _________ (Yr) Summer _________ (Yr)
Number of Academic Internship Credits Desired: _____________
Each credit requires 40 (undergraduate) or 45 (graduate) documented, supervised working hours.
Will register for:
_____ Soc 497 Internship Sociology
_____ Soc 695 Internship: Human Services
_____ Soc 696 Internship: College Teaching
_____ Soc 697 Internship: Sociology
_____ Gero 497 Internship
_____ Gero 498 Practicum: Nursing Home Administration
_____ Gero 697 Internship
_____ Gero 698 Practicum: Nursing Home Administration
Are you a licensed driver? _________
Do you have a car available during placement? ________
Please check or list the courses you have taken:
Sociology:
___ SOC 101 Introduction to Sociology
___ SOC 200 Foundations of Sociology
___ SOC 201 Social Research
___ SOC 202 Introduction to Social Statistics
___ SOC 351 Social Psychology
___ SOC 458 Sociological Theory
___ SOC 463 Social Stratification
___ SOC 406 Applied Sociology
___ SOC 469 Survey Research
___ SOC 479 Sociological Ethnography
___ SOC 480 Social Observation
___ SOC 495 Senior Seminar
___ SOC 602 Seminar in Social Organization
___ SOC 603 Seminar in Social Psychology
___ SOC 604 Sem. in Sociological Statistics
___ SOC 605 Seminar in Research Methods
___ SOC 606 Seminar in Sociological Theory
Other Relevant Courses:
_______________________________________
_______________________________________
_______________________________________
_______________________________________
Nonprofit Leadership:
___ NPL 273 Nonprofit Leadership
___ NPL 473 Nonprofit Leadership
___ RPLS 376 Program Planning
___ URSI 413 Program Evaluation
___ SOWK 469 Social Work Research
___ SOC 466 Program Planning
___ RPLS 473 Adm. of Leisure … Programs
___ URSI 230 Community Leadership
___ SOC 417 Program Administration
___ URSI 453 Grants Administration
___ RPLS 465 Events Management
___ NPL 673 Nonprofit Leadership
___ URBS 513 Urban Program Evaluation
___ SOC 566 Program Planning
___ GWS 600 Collective Action
___ RPLS 573 Admin. of Leisure … Programs
___ SOC 517 Program Administration
___ URSI 553 Grants Administration
___ RPLS 565 Event Management
Gerontology:
___ GERO 200 Aging: Interdis. Perspectives
___ GERO 480 Nursing Home Administration
___ GERO 580 Nursing Home Administration
___ GERO 600 Gerontology Theory and Practice
___ GERO 601 Current Health Issues
_______________________________________
Type your answers to the following questions on a separate page and attach to this application:
1. Describe briefly your career objectives.
2. Placement: Describe the type of placement you would like to have. (Type of agency, type of work,
type of client, geographic location, other relevant characteristics that are important to you.)
3. Employment and Volunteer History: If you have any employment or volunteer history that would
be useful for your internship field and faculty supervisors to know about, please give a brief
description, including location and dates worked or volunteered and your duties. Feel free to attach
your résumé or curriculum vitae.
4. If there is any other information about you or your background that is not requested elsewhere in
this application but which might be relevant to your placement, please provide it as well.
Background: Circle the correct “Yes” or “No” answers
The following questions relate to situations that an employing agency may consider to be risk factors.
Your responses will not necessarily prevent you from entering fieldwork but may require discussion with
the field agency supervisor prior to placement.
It is very important that applicants be honest about such background information. Dishonesty may result
in termination of an internship and a failing grade for the internship course.
If your answer to any of the following questions is “yes,” please explain thoroughly on a separate sheet
and attach it to this application or schedule a private interview with the faculty internship supervisor.
1. Have you ever been charged with or dismissed from a job, internship, volunteer, or
other field related experience for sexual harassment or sexual abuse of clients or
colleagues? ……………………………………………………………………………..
Yes
No
2. Have you ever been treated for chemical dependency? ………………………………..
Yes
No
3. Have you ever been denied, dropped from or failed an internship or other field-based
learning experience?
……………………………………………………………………
Yes
No
4. Have you ever been adjudicated as a juvenile or convicted of an adult criminal offense
(excluding minor traffic crimes)? ……………………………………………………… Yes
No
5. Has your driver’s license ever been suspended or revoked? …………………………… Yes
No
6. Do you have any conditions (physical or otherwise) that will necessitate special
consideration in selection of a field placement? ………………………………………..
If so, please describe your situation on a separate sheet, including need for special
access, restrictions on activity, possibility of acute episodes such as seizures, diabetic
reactions, severe allergic reactions, etc.
Yes
No
Other information:
A Learning Contract signed by the student, faculty supervisor and field supervisor is required before the
student may register for academic credit or start working internship hours. The broad educational
objective for all student interns is to acquire knowledge, skills, and insights that will facilitate entrance
into a professional role and career. Each student identifies specific learning goals in the Learning
Contract. Please see the Learning Contract Template and Writing Instructions on the Internship
Information Webpage at http://sbs.mnsu.edu/soccorr/sociology/internship.html.
AUTHORIZATION AND CERTIFICATION
I give my permission for a copy of this application and related materials to be provided to prospective
field supervisors. To the best of my knowledge, the information provided in this application is true and
accurate. I understand that a failure to demonstrate consistent, good faith performance at the internship or
in fulfilling all of the academic obligations related to the internship course (journals, D2L discussions,
paper, etc.) will result in a failing grade.
Signature ____________________________________________ Date______________________
Please bring the original and one copy of this application to your pre-placement meeting with the
Faculty Internship Supervisor.