STUDENT INFORMATION FORM
–please fill out this information form and send back to Dr. Milligan (either a completed hard copy (via regular mail) or, preferably, completed Word document (via attachment)
STUDENT DATA
Name:
Date:
Student ID#: Major:
Penn State email address:
Local telephone (cell phone #):
Semester standing:
INTERNSHIP SITE DATA
NAME OF INTERNSHIP (if appropriate; leave blank otherwise):
Semester of internship:
Internship begins:
Internship ends:
Number of hours (“site time”) a week:
“ON SITE” INTERNSHIP SUPERVISOR INFORMATION
Name of institution:
Name of “on site” internship supervisor:
Title:
Office address:
“On site” supervisor’s telephone number:
Email address:
ACADEMIC SUPERVISOR FOR YOUR INTERNSHIP
(person must be PSU History Dept. faculty member)
Name of History faculty member, who has agreed to serve as your academic supervisor:
Academic supervisor’s telephone number:
Email address:
HOW CAN YOU BE CONTACTED DURING YOUR INTERNSHIP?
Mailing address:
Residence telephone (cell phone #):
Email address: