Petition To Enroll In Internship Psychology 240 Form printable pdf download

Petition To Enroll In Internship Psychology 240 Form

Internship in Psychology

PETITION TO ENROLL IN INTERNSHIP PSYCHOLOGY 240 FORM, Printable

Read this form through for important information.

SECTION I Student Information

Student Name _____________________________________ Student No. _________________

Address _________________________________________________________________

City_________________________________ State___________________________

Telephone Home _______________________ Work _________________________

E-Mail Address ___________________________________________________________

SECTION II Course Information

Internship in Psychology U09 240 3.0 units Semester: Fall 20____ Spring 20____

Anticipated Beginning Date:__________________

Anticipated Ending Date_____________________

AGENCY APPROVAL

Agency officials: Please do not sign this form authorizing internship at your agency if:

You are signing for work already completed by the student or is significantly underway, or

The student is an employee at your agency, or

Your agency cannot cooperate with Washington University in monitoring student progress by

providing evaluations and certifications to the Internship Coordinator.

Agency Name __________________________________

Contact Person's Name __________________________________

Address __________________________________

E-mail address __________________________________

Telephone __________________________________

Signature __________________________________

Name and qualifications of primary supervisor __________________________________

__________________________________

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Petition To Enroll In Internship Psychology 240 Form