DEPARTMENT OF PSYCHOLOGY APPALACHIAN STATE UNIVERSITY INTERNSHIP AGREEMENT Student’s Name Banner ID ASU e-mail address: Major _Anticipated Graduation Date Estimated Number of Psychology Semester Hours Completed GPA: _ Local Address Phone No. _ Summer Address (if different) _Phone No. _ Emergency Contact (relative; friend): _ Relationship: Phone: _ Their email: Site Name of Internship Address of Internship Phone No. _ Immediate Supervisor _ _ (Name) (Title) Email address of Supervisor: _ Starting Date _Ending Date _ Hours per week: Total Hours to be Completed at Site _120 Hours Credit _ The Psychology Internship Program at Appalachian State University is an attempt to provide students with practical experience in an area relevant to psychology To that end, Appalachian State University and the Department of Psychology will grant hours of academic credit for satisfactory completion of approved work experience Students are required to complete a minimum of work hours per week for hours of academic credit, for a minimum of 120 hours on site, plus other requirements specified below Students are graded based on evaluations by the internship on site supervisor and the Internship Coordinator, based on the quality of completion of all academic and administrative requirements The student understands and agrees to the following provisions: Before registering for the internship the student must be a Psychology Major and cannot be on academic probation or suspension The student can proceed with registration only AFTER the Internship Coordinator has approved and signed the completed internship agreement and sent an electronic approval to the Registrar The intern must register and pay regular tuition and fees The intern must satisfactorily complete all requirements of the work experience that are required by the Department of Psychology These include: a) Provide a weekly log of internship hours b) Provide an email post using the ASULearn Internship course site, every week, with summary reflections of Internship experience c) Write a summary paper at the end of the internship experience, including a reflection of accomplishment of educational objectives that were identified as goals for the Internship experience d) Provide an evaluation to the Internship Coordinator, completed by the Site Internship Supervisor, at the end of the Internship experience e) Provide a class presentation on your site and agency role f) Attend Internship Class meetings, Monday 5:30 pm, every other week The intern is subject to the jurisdiction of all rules, regulations, and codes of conduct affecting students at Appalachian State University, as well as those that the employer may require INTERNSHIP DESCRIPTION To be completed by the Intern and employer: Major Duties/Responsibilities (should list the duties and areas of responsibility for the intern): attach additional sheets if necessary _ _ _ _ _ _ _ _ _ _ _ _ A COMPLETED AGREEMENT FORM WITH INTERNSHIP DESCRIPTION IS NECESSARY PRIOR TO PARTICIPATION IN REGISTRATION Educational Objectives of Internship (see examples from Psychology Internship Site): 1) _ 2) _ 3) _ 4) _ The following signatures confirm understanding and acceptance of the terms of this agreement _ (Student) (Date) _ _ (Employer) (Date) _ _ (Psychology Department Internship Coordinator) (Date) THE AGREEMENT FORM WITH INTERNSHIP DESCRIPTION SHOULD BE DELIVERED TO: Lucinda Payne, M.A Department of Psychology 214 Smith-Wright Hall ASU PO Box 32109 Boone, NC 28608-2109 (828) 262-2272 ext 434 (office) (828) 262-2974 (fax) paynesmithlo@appstate.edu