Fillable Internship Agreement Form 201940 Form

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Internship Agreement Form 201940 Form

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Internship Agreement Form
EAM 4106 – Practicum/Internship
Student Name:
T#:
Address:
City:
State:
Zip:
Email:
Phone:
Anticipated Graduation Term:
Spring
Summer
Fall
Year:
Internship Term:
Spring
Summer
Fall
Year:
Department:
Title:
Address:
City:
State:
Zip:
Email:
Phone:
Fax:
Website:
Dates of Internship:
400 hours Minimum
From:
To:
Hours Per Week:
Compensation:
Unpaid
Paid
If Paid, Amount:
Travel/Living Expense:
None
Yes-Partially
Yes-In Full
Job Description:
The satisfactory completion of this course requires several forms and reports to document and record the student’s
learning experience.
Students are expected to:
Meet with the Internship Coordinator before the beginning of the internship experience to review goals and
expectations.
Submit a completed internship agreement form that is signed by both the student and the Site Supervisor no later
than the Friday prior to the first day of classes for the term in which the internship is to be completed. This form
may be submitted in person or by email. Students will not be registered without a completed form.
Submit all required materials to the Internship Coordinator by the assigned due dates.
Supervisors are expected to:
Provided student interns with a minimum of 400 hour of internship experience.
Provide student interns with work in a pre-professional capacity, and not merely a clerical capacity. Interns are
expected to gain exposure to substantive areas related to emergency management in their work.
Evaluate the intern’s performance at the end of the internship.
The Internship Coordinator is expected to:
Provide support to both the student and the supervisor.
Make on-site visits to the internship site to meet with the site supervisor. (When the site is considerably removed or a
suitable time cannot be coordinated, the evaluation may take place by phone.)
Liability Release and Statement of Non-disclosure:
That in consideration of being allowed to participate in this Internship and receive educational and other benefits
therefrom, the undersigned Intern hereby voluntarily assumes all risks of accident or personal damage to his/her
person or property and hereby releases the above stated Internship Organization, Arkansas Tech University, the
Arkansas Tech University Board of Trustees, the faculty and staff of Arkansas Tech University, as well as any other
respective agents and employees of Arkansas Tech University, from every claim, liability or demand of any kind
sustained, whether caused by negligence or otherwise. This release shall be binding upon any heirs, administrators,
executors and assigns, of the undersigned Intern. The undersigned Intern agrees to the liability release and conditions
set forth for this Internship. In addition, the undersigned Intern understands and agrees to all the terms, conditions,
and requirements set forth in this Agreement Form in accordance with the Intern’s Internship. The undersigned
Intern will not divulge, copy, release, sell, loan, review, alter or destroy records except as properly authorized by the
appropriate official within the scope of applicable state or federal laws, record retention schedule, internal policies,
and departmental procedures.
Internship Agreement:
I agree to fulfill the requirement of this internship to the best of my abilities. I understand that it is my responsibility
to meet all the requirements and submit all required materials, and failure to do so may affect the final course grade
for the internship.
__________________________________________________ ________________
Student Signature Date
I agree to supervise the intern for a minimum of 400 hours. I will evaluate the intern based on his/her performance at
the conclusion of the internship.
__________________________________________________ ________________
Supervisor Signature Date
*Supervisor Note: The student completing this internship should be supervised by a professional staff member within your
organization. The supervisor should not be an individual who is currently enrolled at Arkansas Tech University as an
undergraduate student, or an individual related to the intern.
__________________________________________________ ________________
Internship Coordinator Signature Date
Dr. Jamie Earls, Assistant Professor – Internship Coordinator
Department of Emergency Management at Arkansas Tech University
402 West O Street, Dean Hall Room 110, Russellville, AR 72801
Office: 479-355-2092 Fax: 479-356-2091 Email: jearls@atu.edu
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Internship Agreement Form 201940 Form

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Completed 28 February 2020

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