Human Services Internship Application (HSL 4275)

We require you to provide the needed information for your internship approval request.

Due dates for all paperwork:
December 1st for Spring Semester
April 20th for Summer Semester
August 1st for Fall Semester

Name Name * First Last
E Number *
Enter your EIU/Panther Email, or your request will not be processed. *
Phone Phone * - ### - ### ####
When did/will you complete HSL 4200 or FCS 3500 with a C or higher? *
Semester/Year you wish to enroll. (Example: SP25) *
How many credit hours do you need to enroll in?
(3 credit hours = 120 hours / 6 credit hours = 240 hours)
Must be determined by your site supervisor, and confirmation with your academic advisor. *
Internship Site Name *
Internship Site Address Internship Site Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Internship Site Supervisor (If you do not know who will supervise you when on site, use the name of your current contact person) *
Internship Site Supervisor Email *
Internship Site Web Site *
Internship Site Phone Internship Site Phone * - ### - ### ####
Describe your responsibilities for the internship experience and how they relate to your area of study. Be specific. Make sure your work is proof-read and free of errors. This should be approximately 200-300 words *
Describe three to four objectives specific to your internship experience (what you hope to gain from the internship). This should be approximately 200-300 words in a bullet or listed format. *
Describe your experiential learning activity here (*this is a project that should be different than your daily responsibilities). This should be approximately 200-300 words *
Please confirm the following: *

Please confirm the following: I have discussed everything listed here with the internship site supervisor. My site supervisor has at least a Bachelors degree and is qualified to supervise interns at this site. I have received notice from the site supervisor listed thay I will be approved as an intern. I am not employed by the agency/organization/institution that is my proposed internship site. The site supervisor listed is not my relative or friend.
List any other potential conflicts of interest at this site, and provide rationale as to why this conflict of interest will not affect your internship.
For example, if a family member or friend works at the facility, you need to list it as a conflict of interest. If you do not provide solid rationale as to how this will not affect your work as an intern, your internship application will be denied, and you will need to find another site. *