Internship Registration form

DIRECTIONS
1. Fill out form and read Agreement.
2. Choose "Agree" and signature field will appear.
3. Sign and submit Registration form.
4. Submit any departmental requirements to your University Supervisor.
STUDENTS MUST BE REGISTERED FOR THEIR INTERNSHIP BEFORE BEGINNING WORK.
Name*
First Last
Student ID#*
Are you an international student on an F-1 Visa?
- Yes
- No
PLEASE NOTE: In order to be authorized for an off campus internship/employment, international students must:
1. Complete the Curricular Practical Training Form (CPT).
2. Schedule and attend a CPT appointment with the International Student Services.
Internship Registration will not be approved until these steps are completed.
Student CSP Email address (you will receive a copy of your registration request)*
I am registering as a(n):*
Traditional Undergraduate Department
Adult Undergraduate Department
Other
Major*
Major/Minor (leave blank if no additional majors/minors)
Major/Minor (leave blank if no additional majors/minors
Academic Advisor*
Academic Advisor's Email*
Academic Advisor*
Academic Advisor*
INTERNSHIP SITE INFORMATION
Organization Name*
Organization Address*
Street Address Address Line 2 City State ZIP Code
Organization Website
Site Supervisor/Employer Name*
Site Supervisor/Employer Phone Number*
Site Supervisor/Employer Email Address*
INTERNSHIP PLAN
Title of Internship Position*
Position Description & Responsibilities
Graduate Course Number
Number of Credits
- 2 Credits
- 4 Credits
Dates of Internship (choose closest range)*
Dates of internship will be matched with closest term or part of term for registration. Please contact the Registrar's Office if you have questions about the term for registration.
Number of Credits*
Internship Learning Outcomes
In the boxes below, for each learning outcome, indicate the activities that you will engage in during your internship that will help you achieve that outcome.
Outcome 1 - I will apply academic knowledge to an internship experience. Activities I will engage in include:*
Outcome 2 - I will develop and strengthen skills for professional growth in the field. Activities I will engage in include:*
Outcome 3 - I will Explore professional opportunities within the field. Activities I will engage in include:*
University Supervisor - COM*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - ENG*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - HIS*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - PSY or SOC*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - MAT*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - MAN*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - MAR*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - MUS*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - ART*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - BIO*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - CHE*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - THR*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor - Education*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor
University Supervisor*
The University Supervisor is the Concordia Faculty member that will collect your supplemental documents and approve and supervise your internship.
University Supervisor's Email*
INTERNSHIP TERMS AND CONDITIONS

Concordia University, St Paul itself does not control the way in which this educational opportunity is structured or operates on a daily basis. In granting credit for this internship/practicum experience, the University affirms that to the best of its knowledge the experience is an appropriate curricular option for students seeking work-related experience but makes no other assurances, expressed or implied about any travel, wages, or living arrangements made by the student and employer.

Concordia University does not knowingly approve internship or practicum opportunities which pose undue risk to their participants. However, any program or travel carries with it potential hazards which are beyond the control of the Lutheran Church-Missouri Synod, Concordia University, its Board of Regents, officers, and its agents or employees.

INSURANCE COVERAGE
• I have health, accident and hospitalization insurance to cover me during my internship; I further understand that I am responsible for the costs of such insurance and for any expenses not covered by the insurance and I recognize that Concordia University does not have an obligation to provide me with such insurance. The activities of this agreement do not create an employer-employee relationship in any manner and I will not be entitled to any form of workers’ compensation benefits.
• I assume full responsibility for any undisclosed physical or emotional problems that might impair my ability to complete the experience and I forever release Concordia University from any liability whatsoever for injury to myself or damage to or loss of my possessions.
• I understand that if I use my personal vehicle for the benefit of the organization with whom I perform my internship/practicum, Concordia University has no liability for personal injury or property damage which may result from that use. I agree to rely solely on my personal vehicle insurance coverage and on any insurance which may be provided by my internship site. In addition, I shall not seek reimbursement for any non-covered expenses or policy deductibles that I may incur as a result of using my personal vehicle for the activities stated herein this agreement.
• I understand that I will not be entitled to unemployment compensation benefits upon completion of my internship. Further, I understand that Concordia University assumes no liability for personal injury that I may suffer in the course of my internship and I agree to be responsible for ascertaining whether my internship site provides workers compensation coverage for me.

PERSONAL CONDUCT
• I understand that the responsibilities and circumstances of an off-campus internship or practicum may require a standard of professional decorum that may differ from that of Concordia University. Therefore, I indicate my willingness to understand and conform to the professional standards of the internship site. I further understand that it is important to the success of the present internship/practicum and the continuances of future experiences that interns observe standards of conduct that would not compromise Concordia University in the eyes of individuals and organizations with which it has dealings.
• I acknowledge the responsibility of Concordia University and the Internship Supervisor to set rules and interpret conduct for this purpose. I agree that should Concordia University or the Internship Supervisor decide that I must be terminated from my experience because of conduct that might bring the program into disrepute or the internship site into jeopardy, that decision will be final and may result in loss of academic credit.

GENERAL RELEASE
• I understand that Concordia University reserves the right to make cancellations, changes or substitutions in cases of emergency or changed conditions or in the general interest of its Internship/Practicum Program at any time.
• It is further expressly agreed that the internship/practicum site and use of any or all of its facilities shall be undertaken by me at my own sole risk and that Concordia University shall not be liable for any and all claims, demands, injuries, damages, actions or causes of actions, whatsoever to me or property arising out of or connected with the experience and with the use of any and all services, or facilitates associated with the internship whether or not sponsored by Concordia University. I release and forever discharge Concordia University, their agents and servants, successors and assigns, directors, trustees, officers, employees, and other representatives from any and all liability, causes of action, claims, or damages arising out of or related to any loss, damage, or injury sustained by any person (including myself) from any and all present or future claims, demands or actions in law or in equity that may hereafter be made or brought by me as a result of this experience.
• Concordia University, St Paul is committed to reasonable accommodations for students with qualified disabilities (including mental health and medical conditions). Any student considering an internship or other experience outside of the traditional classroom who may require accommodations should speak with Student Accessibility Services prior to the commencement of the experience. This is to ensure modifications are implemented in a reasonable time frame.
Internship Agreement*
- I have read this agreement and understand the conditions of my internship. I agree to abide by my responsibilities as outlined here. I also understand that I am responsible for all payments related to tuition and fees for internship credit.
- I do not agree to abide by the terms of the Internship Agreement
SIGNATURE (must choose "agree" above for signature fields to appear)
Signature*
By signing (typing my name) below, I also understand I am responsible for all payments related to tuition and fees for internship credit.
Date*

Internship Registration Form

DIRECTIONS

INTERNSHIP SITE INFORMATION

INTERNSHIP PLAN

SIGNATURE (must choose "agree" above for signature fields to appear)