Application for Internship in

Sociology, Gerontology and Sociology for Nonprofit Leadership

Information provided will be used to determine eligibility for the Internships for Sociology, Gerontology, Nonprofit Leadership. Submit one copy to the faculty supervisor and one to the field supervisor. Please respond to all items.

Name: ______Date______

Tech ID # ______Phone: ______

Campus Email: ______

Local Address: ______

(Street Address, Apt. #)

______

(City)(State)(Zip)

Permanent Address:______

(Street Address, Apt. #)

______

(City)(State)(Zip)

In case of an emergency, notify ______

Relationship: ______ Phone: ______

Undergraduate Student ______orGraduate Student ______

Major(s): ______

Minor(s): ______

Certificate(s): ______

Cumulative GPA: ______Projected Graduation Date: ______

Desired term(s) for placement: Fall ______(Yr) Spring ______(Yr) Summer ______(Yr)

Number of Academic Internship Credits Desired: ______

Each credit requires 40 (undergraduate) or 45 (graduate) documented, supervised working hours.

Will register for: _____ Soc 497 Internship Sociology

_____ Soc 695 Internship: Human Services

_____ Soc 696 Internship: College Teaching

_____ Soc 697 Internship: Sociology

_____ Gero 497 Internship

_____ Gero 498 Practicum: Nursing Home Administration

_____ Gero 697 Internship

_____ Gero 698 Practicum: Nursing Home Administration

Are you a licensed driver? ______Do you have a car available during placement? ______

Please check or list the courses you have taken:

Sociology:

___ SOC 101Introduction to Sociology

___ SOC 200Foundations of Sociology

___ SOC 201Social Research

___ SOC 202Introduction to Social Statistics

___ SOC 351Social Psychology

___ SOC 458Sociological Theory

___ SOC 463Social Stratification

___ SOC 406 Applied Sociology

___ SOC 469Survey Research

___ SOC 479Sociological Ethnography

___ SOC 480Social Observation

___ SOC 495Senior Seminar

___ SOC 602 Seminar in Social Organization

___ SOC 603 Seminar in Social Psychology

___ SOC 604 Sem. in Sociological Statistics

___ SOC 605 Seminar in Research Methods

___ SOC 606 Seminar in Sociological Theory

Other Relevant Courses:

______

______

______

______

______

Nonprofit Leadership:

___ NPL 273 Nonprofit Leadership

___ NPL 473 Nonprofit Leadership

___ RPLS 376 Program Planning

___ URSI 413 Program Evaluation

___ SOWK 469 Social Work Research

___ SOC 466 Program Planning

___ RPLS 473 Adm. of Leisure … Programs

___ URSI 230 Community Leadership

___ SOC 417 Program Administration

___ URSI 453 Grants Administration

___ RPLS 465 Events Management

___ NPL 673 Nonprofit Leadership

___ URBS 513 Urban Program Evaluation

___ SOC 566 Program Planning

___ GWS 600 Collective Action

___ RPLS 573 Admin. of Leisure … Programs

___ SOC 517 Program Administration

___ URSI 553 Grants Administration

___ RPLS 565 Event Management

Gerontology:

___ GERO 200 Aging: Interdis. Perspectives

___ GERO 480 Nursing Home Administration

___ GERO 580 Nursing Home Administration

___ GERO 600 Gerontology Theory and Practice

___ GERO 601 Current Health Issues

Type your answers to the following questions on a separate page and attach to this application:

  1. Describe briefly your career objectives.
  1. Placement: Describe the type of placement you would like to have. (Type of agency, type of work, type of client, geographic location, other relevant characteristics that are important to you.)
  1. Employment and Volunteer History: If you have any employment or volunteer history that would be useful for your internship field and faculty supervisors to know about, please give a brief description, including location and dates worked or volunteered and your duties. Feel free to attach your résumé or curriculum vitae.
  1. If there is any other information about you or your background that is not requested elsewhere in this application but which might be relevant to your placement, please provide it as well.

Background: Circle the correct “Yes” or “No” answers

The following questions relate to situations that an employing agency may consider to be risk factors. Your responses will not necessarily prevent you from entering fieldwork but may require discussion with the field agency supervisor prior to placement.

It is very important that applicants be honest about such background information. Dishonesty may result in termination of an internship and a failing grade for the internship course.

If your answer to any of the following questions is “yes,” please explain thoroughly on a separate sheet and attach it to this application or schedule a private interview with the faculty internship supervisor.

  1. Have you ever been charged with or dismissed from a job, internship, volunteer, or other field related experience for sexual harassment or sexual abuse of clients or colleagues? ……………………………………………………………………………..
/ Yes No
  1. Have you ever been treated for chemical dependency? ………………………………..
/ Yes No
  1. Have you ever been denied, dropped from or failed an internship or other field-based learning experience? ……………………………………………………………………
/ Yes No
  1. Have you ever been adjudicated as a juvenile or convicted of an adult criminal offense (excluding minor traffic crimes)? ………………………………………………………
/ Yes No
  1. Has your driver’s license ever been suspended or revoked? ……………………………
/ Yes No
  1. Do you have any conditions (physical or otherwise) that will necessitate special consideration in selection of a field placement? ………………………………………..
If so, please describe your situation on a separate sheet, including need for special access, restrictions on activity, possibility of acute episodes such as seizures, diabetic reactions, severe allergic reactions, etc. / Yes No

Other information:

A Learning Contract signed by the student, faculty supervisor and field supervisor is required before the student may register for academic credit or start working internship hours. The broad educational objective for all student interns is to acquire knowledge, skills, and insights that will facilitate entrance into a professional role and career. Each student identifies specific learning goals in the Learning Contract. Please see the Learning Contract Template and Writing Instructions on the Internship Information Webpage at

AUTHORIZATION AND CERTIFICATION

I give my permission for a copy of this application and related materials to be provided to prospective field supervisors. To the best of my knowledge, the information provided in this application is true and accurate. I understand that a failure to demonstrate consistent, good faith performance at the internship or in fulfilling all of the academic obligations related to the internship course (journals, D2L discussions, paper, etc.) will result in a failing grade.

Signature ______Date______

Please bring the original and one copy of this application to your pre-placement meeting with the Faculty Internship Supervisor.