Fillable Independent Study Internship With Ammon Addendumv3 Fillable (Central Connecticut State University)

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Independent Study Internship With Ammon Addendumv3 Fillable (Central Connecticut State University)

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Central Connecticut State University
Office of the Registrar
Independent Study/Internship Course Registration Form
Student Information
Name:
CCSU ID:
Email:
Street:
Telephone No.:
City/State/Zip:
Major:
Year
Term
Full/Part-Time
Ind Study/Internship
To be completed by student and faculty member:
Faculty Sponsor:
Faculty Load Credit:
Course Number:
Course Title:
Credit Hrs. (e.g., 3):
Average Weekly Contact Hrs. (e.g., 3, 4, 6):
CCSU Meeting Place (classroom, office):
List off-campus sites (if international, list country):
Course description and its relationship to student’s program
Criteria and schedule for assessing student performance
Planned readings and/or assignments
I understand that registering for classes at Central Connecticut State University will generate charges that I am legally obligated to
pay in accordance with University payment deadlines and/or formal withdrawal policies. I also understand that any unpaid
obligations may be referred to the University’s contracted collection agency and that I will be responsible for any related collection
costs in addition to the amount due.
Student’s Signature
Date
Printed Name
Faculty Signature
Date
Printed Name
Department Chair Signature
Date
Printed Name
Dean of Academic Department Signature
Date
Printed Name
Dean of Graduate Studies Signature (if needed)
Date
Printed Name
Please print this form and submit it to the Office of the Registrar for processing.
Davidson Hall, Room 116, 1615 Stanley Street, New Britain CT, 06050, fax it to 860-832-2250, or email it to regstaff@ccsu.edu
Ammon College of Liberal Arts and Social Sciences Independent Study Form Addendum
To be completed by faculty:
Please fill out all sections below and attach to the independent study form. Requests for
independent study courses will not be reviewed until this form is complete.
Student Name:
________________________________________
Student CCSU ID:
________________________________________
Student Major:
________________________________________
Check one:
UNDERGRADUATE GRADUATE
Course Number (e.g., HIST 493):
________________________________________
Course Title:
________________________________________
Academic Term & Year:
________________________________________
Faculty Name:
________________________________________
Faculty Department:
________________________________________
Total Faculty Load for Semester in Which Course Will be Taught ________________________
Is this course required for everyone in the student’s major or minor? YES NO
If NO, please explain the objectives of the independent study and the role this course will play in the student’s
program. (A few sentences should suffice.)
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Completed 24 July 2020

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