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Internship Provider Form

Student Name:

Date internship begins:

Date internship ends:

Hours per week the student will work:

Will Fridays be free for the student?

Yes No

Organization:

Area Code & Phone:

Address:

Internship Website:

Student's Work Supervisor:

Student Position:

Supverisor's Phone:

Work Supervisor Email:

Will you provide mid-semester and final evaluations of the student?

Yes No



Summary of work assignments the student will be given on this internship: