FALL 2015 INTERNSHIPS

Info packet & required forms are on my website: www.wou.edu/~robertsjl, then click on

Internships linkEXERCISE SCIENCE COMMUNITY HEALTH EDUCATION

120 hours required (12 hrs/week) 240 hours required (24 hrs/week)

Terms runs from Sept 28th – December 4th.

Hours cannot be started until Sept 28th and forms MUST be received on Sept 29th.

If forms are late, hours may NOT be counted until forms are received.

Once you identify a site – it must be approved by me.

Complete Forms A, B & C Salem Hospital, Samaritan Health Services &

Marion Co Health Department do NOT need Form A – everyone else does!

TYPED except for signatures Handwritten forms will NOT be accepted Incomplete forms – 5 points will be deducted

from final grade for each incomplete form. Completed forms are due at next meeting.

Form A – Master Agreement

This agreement is entered into this ___ day of ___ 20__ (“Effective Date” between Western Oregon University (WOU), an Oregon non-profit cooperation and education institution (WOU), and ____ (The “Experience Provider”) located at _____.

First line example: 20th day of April 2015 _______ (The “Experience Provider”) = company name NOT

person’s name Located at __________ = physical address (street address,

city, state, zip)

Make sure ALL blanks are filled in The Experience Provider = the name of the company where you will

be interning.

Form A continued – Page 1

For Experience Provider: For WOU:

Name: Name: Janet Roberts

Address: Address: 345 N. Monmouth Ave

Telephone: Telephone: (503) 838-8446

Email: Email: robertsjl@wou.edu

NOTE: For Experience Provider: name may or may not be supervisor’s name it might be legal representation of the company or human resources director, etc.

Form A – Master Agreement page 2Experience Provider: Western

Oregon University:

By: (Signature) By: I will sign

Name: Print name Name: I will print my name

Date: Date:

Form B – Student AgreementStudent Name: Your name

Internship Start Date: 9/28/2015 End Date: 12/4/2015

Department and Course Number: Either HE419 or EXS419

Quarter Enrolled: Fall Year: 2015 Credit Hours: 8/4

Internship Site (“Experience Provider”): Internship Company Name

Complete Internship Address: Street #, Street, City, State, Zip

Site Supervisor: Supervisor’s first and last name

Phone: Supervisor’s phone# Email: Supervisor’s email

Form C - Objectives

Fill out the top of the form Do NOT hand forms to your site

supervisor to fill out! Objectives need to be TYPED and in

correct format (see instructions) “To research fall prevention programs by

July 15th, 2015.”

Form C continued

You will need to meet with your site supervisor before you start your internship to determine objectives.

KEEP a copy of form C for your records.

Upcoming Meetings

Meetings are MANDATORY!!

Tuesday, Sept 29th, 4pm, location TBD

Finals week: date, time and location TBD

Check WOU email regularly

HE419 – CRN 11251 – 8 credits – A-F

EXS419 – CRN 11264 – 4 credits – A-F