PART I

1. 
   

   Name _________________________________ Campus Address Box #______ Muhlenberg College, Allentown, PA 18104 ______________ phone # __________________________ email	Berg ID # _______________________ Home Address _______________________________ street _______________________________ city                               state         zip _______________________________ phone #
   Your residential address while on the internship, if away from campus: __________________________________________________________________________ street __________________________________________________________________________
   city	state                         zip
   ________________________________ phone #	________________________________ fax #

   
   

2. 
   Internship organization: __________________________________________
   

   Address:

   ________________________________________________________ street                                             city                                       state         zip

   Mailing Address, if different than above: _____________________________
   

   Site Supervisor:

   __________________________________________________ name                                                   title

   Phone #: ______________________________

   
   

3. 
   

   Faculty Sponsor:

   ________________________________________________________________ name                                                                    department

   Office: ___________________________________     Phone #: ________________
   

   Academic Advisor:

   ________________________________________________________________ name                                                                    department

   
   Office: ___________________________________     Phone #: ________________

1. JOB DESCRIPTION: Describe your role and responsibilities while on your internship. List duties, projects, deadlines and so on.

   
   
   
   
   
   
   
   

2. HOURS: You are encouraged to set regular weekly hours for the duration of your internship. In order to receive academic credit, you must work 9-12 hours per week, and a total of 126-168 hours per semester. For summer internships, you must work no less than 126 hours. Please list hours:

   Day

   Hours

   
   
   
   
   

3. SUPERVISION: Describe the supervision to be provided by your site supervisor, faculty sponsor or others. What kind of instruction, assistance or consultation will you receive and from whom?

1. LEARNING OBJECTIVES: What do you intend to learn through this experience? What abilities, skills, or knowledge do you intend to develop or enhance? Be specific. Use concrete, measurable terms.

   
   
   
   
   
    

2. LEARNING ACTIVITIES:

   1. On-the-job: Describe your activities and how they will enable you to meet your learning objectives. Include projects, research, report writing, conversations which you will carry out while working, relating them to what you intend to learn.

   
   
   
   
   
   
   2. Academic and off-the-job: Describe in as much detail as possible your academic project. Also list reading, writing, contact with your faculty sponsor and other students, discussions, field trips, and/or observations you will carry out which will help you meet your learning objectives.

   
   
   
   
    

PART IV: EVALUATION

How will you know what you have learned, or that you have achieved your learning objectives? How will your work performance be evaluated? By whom? When? How will a grade be determined? By whom? When? All parties should receive a copy of the evaluation form at the start of the internship experience.

PART V: AGREEMENT

This agreement may be terminated or amended by the student, faculty instructor or site supervisor upon written notice, which is received and agreed to by the other two parties. This is a working agreement and does not constitute a contractual obligation for any of the parties concerned.




Student signature: ____________________________	Date: __________________
Faculty instructor: ____________________________	Date: __________________
Site supervisor: ______________________________	Date: __________________

(Copies of this signed agreement should be distributed to the student, faculty sponsor and site supervisor.)