Internship Registration Form

Semester__________________________ Year_____________

COMPLETE AND RETURN TO THE CGSP OFFICE: Kelly Niles-Yokum, 484 MAIN STREET, SUITE 500, WORCESTER, MA 01608.
ALL FORMS MUST BE RETURNED BY September 15 (FALL SEMESTER)
February 1 (SPRING SEMESTER)
June 1 (SUMMER SESSION)

STUDENT NAME_________________________________________PHONE______________________

SCHOOL_____________________________________________________________________________

INTERNSHIP
AGENCY ___________________________________________________________________________

AGENCY AGENCY
ADDRESS ___________________________________________ PHONE _________________
street
_____________________________________________________________________________________
city state zip
INTERNSHIP
SUPERVISOR_________________________________________________________________________

TITLE______________________________________________

FACULTY SUPERVISOR/
SEMINAR INSTRUCTOR_________________________________________________________________

COURSE/SEMINAR NUMBER/TITLE_______________________________________________________
Example: SRS490-01 Individual in Community

INTERNSHIP _______________________ ________________________
ASSIGNMENT day time
HOURS _______________________ ________________________
day time
_______________________ ________________________
day time
Starting Date______/_______/______ Ending Date______/________/_______

____________________________________________ ___________________
signature of student date
____________________________________________ ___________________
Signature of internship site supervisor date

3/00

 

CGSP INTERNSHIP REGISTRATION FORM INSTRUCTIONS

  • All students who will be beginning their internships for credit toward the gerontology certificate must register their internship with the CGSP Office by completing the CGSP Internship Registration Form
  • The form must be completed in full – with all signatures, addresses and phone numbers provided.
  • Forms should be sent directly to the CGSP Office at: 484 Main Street, Suite 500, Worcester, MA 01608
  • Deadlines for submission of the Internship Registration Form are:
    • September 15 for the fall semester
    • February 1 for the spring semester
    • June 1 for the summer sessions
  • Students failing to submit this form will not receive gerontology credit for their internship.