Student is responsible for completing this form (with student, faculty adviser and employer signatures) and returning it to the Career
Services Center (SSC 3258).
Student Information
Student’s Name (Print) Date
Total Internship Credit Hours Field of Study
Email Faculty Adviser’s Name
Phone Student’s Position Title
Wage: $ / Hr Non-Paid
Employer/Supervisor Information
Company/Agency Name (Print)
Supervisor’s Name Telephone Number
Supervisor’s Title Email
Student & Faculty Adviser
List measurable learning goals based on the internship description, which will improve assessed skills. This portion should be completed by the
student and faculty adviser in consultation with the employer.
1. Learning Goal:
Learning Plan:
Evaluation Rubric:
2. Learning Goal:
Learning Plan:
Evaluation Rubric:
3. Learning Goal:
Learning Plan:
Evaluation Rubric:
4. Learning Goal:
Learning Plan:
Evaluation Rubric:
Use an additional sheet, if desired. 75 hours of work = 1 credit
We agree to the learning goals listed above.
The employer agrees to supervise and mentor the student
in a safe environment.
The faculty adviser agrees to guide student learning and
assign a grade.
The student agrees to meet or exceed the stated goals
and work requirements.
STUDENT SIGNATURE
FACULTY ADVISER SIGNATURE
ASSOCIATE DEAN SIGNATURE
EMPLOYER/SUPERVISOR SIGNATURE
Career Services Center | SSC 3258 | 425 Fawell Blvd. | Glen Ellyn, IL 60137-6599 | (630) 942-2230
CARSERV-13-12211(R12/13)
Learning Agreement
College of DuPage
