Internship Registration Form
College of Health, Science, & Technology
Company Information
The Fine Print
Student Information - Form Must Be Typed
Name _______________________________________________________ ❏ Male ❏ Female
Student I.D. # (7 number) ____________________________ Cum. GPA _________
Major _________________________________________________________________________
Total undergraduate/graduate hours completed at time of internship: _________
During the internship period, the intern may be reached at:
Street ____________________________________________ Phone (_____) _____ – _______
International Phone ____________________________________________________________
City _______________________________________________, State _____ Zip __________
Email____________________________@ucmo.edu Cell (_____) _____ – ______________
Alternate Email _______________________________________________________________
Visit www.ucmo.edu/technology/intern/ for instructions on completing this form.
Company Name __________________________________________________________________
Street _________________________________________________________________________
City _________________________________________, State _____ Zip _____________________
Name of Company Supervisor ________________________________________ ❏ Male ❏ Female
Title of Company Supervisor_________________________ Supervisor’s Phone (_____) _____ – _________
Supervisor’s Email_______________________________ Supervisor’s Fax (_____) _____ – __________
International Supervisor’s Phone ________________________________________________________
International Supervisor’s Fax __________________________________________________________
Company’s Website _____________________________ Intern’s Work Phone (_____) _____ – _________
Intern’s International Phone Number ______________________________________________________
Intern’s Job Title & Job Description _______________________________________________________
_____________________________________________________________________________
Contact Information
Course Information
Work Information
Office Use Only
Notes:
I have read the requirements for this internship as stated in the Internship Syllabus, available at
www.ucmo.edu/technology/intern, and agree that my grade will be determined by how well I meet the requirements and how
my supervisor evaluates my work and attitude on the job. I understand that it is my sole responsibility to complete all of the
requirements. I understand that all tuition fees (including those for this internship) must be paid to prevent automatic drops. It
is my sole responsibility to ensure I have adequate insurance to cover accidents and illnesses while participating in the intern-
ship. The University is not responsible for accidents, illness, injury or damages sustained while participating in this program.
_____________________________________________________________________________
Student Signature Date
_____________________________________________________________________________
Major Program
Faculty Advisor Date
_____________________________________________________________________________
UCM Internship Coordinator Date
Grinstead 009, Warrensburg, MO 64093
Offi
ce: 660-543-8697
Fax: 660-543-4578
techinterns@ucmo.edu
www.ucmo.edu/technology/intern/
Course
❏ SOT 3022 (undergraduate)
❏ SOT 5022 (graduate)
Term Enrolling:
❏ Summer ❏ Fall ❏ Spring
Year Enrolling: 20____
Credit Hours:
❏
1 ❏ 2 ❏ 3 ❏ 4 ❏ 5 ❏ 6
Your Faculty Advisor:
____________________________
Start Date ___________________
End Date ___________________
❏ Part Time ❏ Full Time
Days Worked:
❏ S ❏ M ❏ T ❏ W ❏ T ❏ F ❏ S
This Internship Is:
❏ Paid ❏ Unpaid
Select from drop down list
