IU South Bend Intern Learning Agreement Form

The IU South Bend Intern Learning Agreement Form should be completed by IU South Bend students who are beginning an internship course or experience. To complete the form, please have your: student information (student ID number, major, & minor), information about the organization where you are interning, contact information for the person you are working with at the internship site, and the name and contact information for the IU South Bend faculty or staff member teaching your internship course (if your internship is for academic credit).

Your name

First

Last

Your student ID number

Your IU email address

Your phone number

Your major

Your minor

Please list the semester and year when you will pursue your internship.

Provide the name of your IU South Bend Internship Coordinator (this should be the faculty or staff member from IU South Bend who is teaching your internship course or providing oversight for your internship experience).

Provide your IU South Bend Internship Coordinator's email address (this should be the IU email address for the faculty or staff member from IU South Bend who is teaching your internship course or providing oversight for your internship experience).

List the name & number of your internship course (ex: SOC S494, Internship in Sociology).

How many academic credit hours will you receive for your internship course? Please note: The number of academic credits you receive usually depends on the number of hours you plan to work in your internship and should be discussed with your IU South Bend Internship Coordinator.

How many hours do you plan to work at your internship this semester?

Is the internship on or off campus?

on campus
off campus

Provide the name of business, agency, or organization where you will intern.

Provide the address of the organization where you will intern.

Address

Address 2

City

State/Province/Region

Zip code

Country/Region

Provide the name and title for your supervisor (or the person you will work with) at the internship site.

Name

Job Title

Provide a phone number for your supervisor at the internship site.

Phone number with area code:

Provide an email address for your supervisor at the internship site.

Is this internship paid?

Yes
No

List your job title in the internship position.

Provide a brief description of the internship duties and responsibilities.

When does your internship start?

Month/Day/Year

When does your internship end?

Month/Day/Year

What is your weekly work schedule at your internship? Please list days and times (ex. Mon, Wed, Fri 12:00 pm to 5:00 pm).

What are your personal goals for your internship?