Human Services Program
Form 6

Form 6: Weekly Internship Schedule

DAY / TIMES
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Alternate
Scheduling
Arrangements / 1 This schedule will change weekly given the nature of the work.
1 Schedule may occasionally include evening and weekend hours.
1 There are dates when the field supervisor will not be available (vacation/conference/family leave) during the term. Dates: ______
Will the intern continue their placement during this time?
Yes 1 No 1
1 There are dates when the intern will not be available (vacation/planned absence/family leave) during this term. Dates: ______
TOTAL Weekly Hours:______
The above schedule has been agreed upon by the field supervisor and the intern.
______
Student Name (Please print) Date
Agency Name and Address: ______
Field Supervisor Name: ______

9-8-16