Purchasing & Contract Administration	PURCHASING & CONTRACT ADMIN. TEL NO: (818) 677-2301 FAX NO: (818) 677-6544 MAIL DROP: 8231
	Internship Learning Plan

I. STUDENT APPLICANT:
FIRST NAME:	MIDDLE INITIAL:	LAST NAME:		STUDENT FILE NUMBER:
STREET ADDRESS:		CITY:	STATE:	ZIP + 4:
TELEPHONE:	EMAIL ADDRESS:	EMERGENCY CONTACT FOR STUDENT:		TELEPHONE:

COURSE INSTRUCTOR:	SEMESTER/QUARTER:	PHONE NUMBER :	FAX NUMBER:	EMAIL ADDRESS:
COURSE NUMBER:	TICKET NUMBER:	NUMBER OF UNITS:

AGENCY / SITE:	SITE ADDRESS:		PHONE NUMBER:
SITE SUPERVISOR:	PHONE NUMBER:	APPROX. # OF HOURS:	START DATE:	END DATE:

II. LEARNING OBJECTIVES:

WHAT DO YOU HOPE TO LEARN FROM THIS EXPERIENCE - ABOUT THE AGENCY, ABOUT THE CHALLENGES AND ASSETS OF THE POPULATION WITH WHOM YOU WILL BE WORKING, ABOUT YOURSELF, AND ABOUT YOUR COMMUNITY - AND HOW DOES THIS CONNECT TO YOUR COURSEWORK?

III. SITE SUPERVISOR:
1.	AGREES TO GUIDE THIS STUDENT'S WORK AND TO SUBMIT A BRIEF, FINAL EVALUATION OF HIS/HER ACHIEVEMENT UPON REQUEST.
2..	AGREES TO DISCUSS ANY CONCERNS ABOUT THE LEARNER'S PERFORMANCE WITH HIM/HER DIRECTLY, AND WITH THE COURSE SUPERVISOR IF NECESSSARY.

Site Supervisor Signature: ________________________________________

Date: ___________

IV. FACULTY COURSE SUPERVISOR:

I have examined and approved 's Internship Learning Plan.

Faculty/Course Supervisor Signature: _____________________________		Date: ___________
Student Initials:

	Purchasing & Contract Admin.	PURCHASING & CONTRACT ADMIN. TEL NO: (818) 677-2301 FAX NO: (818) 677-6544 MAIL DROP: 8231
	Internship Learning Plan

I. THE STUDENT:
1.	Agrees to act in a responsible manner while representing California State University at the internship placement site, and abide by all rules and regulations that govern the site in which he/she has been placed.
2.	Understands the connection between the course, and the learning objectives to be fulfilled at the service site.
3.	Has participated in orientation and read the above-stated guidelines and limitations, and understands his/her role as an internship student in working with the community partner.
4.	Understands the following RISKS may exhist with this internship placement, and enters into this placement fully informed and aware.
5.	Agrees to devote hours per week for a total of hours, effective from to in order to fulfill the objectives described above.
6.	Agrees to complete any forms, evaluations or other paperwork required by either the course or the Site Supervisor.
	Student Signature: ________________________________	Date: ___________