Effective 20180522
Richard W. Riley College of Education
Winthrop University
REQUEST FOR COURSE WITH INTERNSHIP
Purpose: This form is used for any student wishing to request permission to take additional coursework beyond the
Internship II course, a program area capstone course, and EDUC 410.
Student Name Student Number
Student E-mail __________________________________________ Degree/Major
Current Phone Expected Grad. Date ____________________________
Cumulative GPA: __________ Last Semester GPA: ___________ Hours Completed: __________
Clear, brief statement of request (REQUIRED): Check here if attaching documents.
Clear, brief rationale for request (include what happens if request is denied) (REQUIRED):
Signature of Student _____________________________________________ Date ________________
To be completed by Advisor: _____ Support _____ Support with Reservations _____ Do Not Support
Rationale (REQUIRED):
Signature of Advisor _____________________________________________ Date ________________
To be completed by Program Director: _____ Support _____ Support with Reservations _____ Do Not Support
Rationale (REQUIRED for Secondary and K-12 Arts & Sciences and Visual & Performing Arts):
Signature of Advisor _____________________________________________ Date ________________
To be completed by Department Chair: _____ Support _____ Support with Reservations _____ Do Not Support
Rationale (REQUIRED):
Signature of Department Chair ________________________________________ Date ________________
AFTER OBTAINING SIGNATURES, SUBMIT THIS FORM TO: STUDENT ACADEMIC SERVICES, 144 WITHERS
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