Registration for Academic Credit

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1. Last Name

Last Name

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2. First Name

First Name

3. Middle Initial

Middle Initial

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4. Student ID#

Student ID#

5. Address (during work experience)

Address (during work experience)

6. City

City

7. State

State

8. Zip

Zip

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9. Phone

Phone

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10. Cell Phone (be sure to include area code)

Cell Phone (be sure to include area code)

11. Campus Address

Campus Address

12. Campus Phone

Campus Phone

13. Campus Box #

Campus Box #

14. Email (other than campus mail - e.g., Gmail or Hotmail)

Email (other than campus mail - e.g., Gmail or Hotmail)

15. Citizenship Status

Citizenship Status United States of America

Permanent Resident

Student Visa - F-1

Student Visa - J-1

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16. Major

Major

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17. Date of Graduation

Date of Graduation

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18. Academic Advisor (last name, first name)

Academic Advisor (last name, first name)

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19. GPA (Go to MCSquare and look in DegreeWorks or your unofficial grade report. Copy and paste into Word the page which verifies your GPA. Email that to the Internship Center - internctr@messiah.edu)

GPA (Go to MCSquare and look in DegreeWorks or your unofficial grade report. Copy and paste into Word the page which verifies your GPA. Email that to the Internship Center - internctr@messiah.edu)

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20. Your Position Title (do not type "Intern" - e.g., Research Assistant, Editorial Assistant, etc.)

Your Position Title (do not type "Intern" - e.g., Research Assistant, Editorial Assistant, etc.)

21. I am registering for:

I am registering for:

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22. Hours per week (minimum is 10)

Hours per week (minimum is 10)

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23. Start Date (e.g. - 9/12/12)

Start Date (e.g. - 9/12/12)

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24. End Date (e.g. - 12/7/12)

End Date (e.g. - 12/7/12)

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25. Total Weeks (12 weeks minimum)

Total Weeks (12 weeks minimum)

26. Compensation (How much will you be paid per hour? If you are not being paid, type "0")

Compensation (How much will you be paid per hour? If you are not being paid, type "0")

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27. There are academic assignments you will be required to complete.

Grantham students - Both INTE394 and INTE395 meet on Tuesday from 5:30-7:30 p.m. Do NOT schedule other classes during this time.

Summer students - INTE391 and INTE394 credits are available. A Pre and Post-Summer class will be scheduled.

Film students - you may not register UNTIL you have an acceptance/approval email from the Communications Dept. Chair and have forwarded it to the Internship Center.

Course Registration
- INTE391 - available to Sophomores through Seniors (pass/fail, or letter-graded if approved by your academic dept. in writing prior to registration)
- INTE394 - available to Juniors and Seniors - Monthly Class (letter-graded)
- INTE395 - available to Juniors and Seniors - Weekly Class (letter-graded)

There are academic assignments you will be required to complete. Grantham students - Both INTE394 and INTE395 meet on Tuesday from 5:30-7:30 p.m. Do NOT schedule other classes during this time. Summer students - INTE391 and INTE394 credits are available. A Pre and Post-Summer class will be scheduled. Film students - you may not register UNTIL you have an acceptance/approval email from the Communications Dept. Chair and have forwarded it to the Internship Center. Course Registration - INTE391 - available to Sophomores through Seniors (pass/fail, or letter-graded if approved by your academic dept. in writing prior to registration) - INTE394 - available to Juniors and Seniors - Monthly Class (letter-graded) - INTE395 - available to Juniors and Seniors - Weekly Class (letter-graded)

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28. Name of Organization

Name of Organization

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29. Organization Address

Organization Address

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30. Organization City

Organization City

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31. Organization State

Organization State

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32. Organization Zip

Organization Zip

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33. Organization Supervisor

Organization Supervisor

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34. Supervisor Title

Supervisor Title

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35. Supervisor Phone

Supervisor Phone

36. Supervisor Fax

Supervisor Fax

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37. Supervisor Email (we must have a valid email address)

Supervisor Email (we must have a valid email address)

38. Organization Website

Organization Website

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39. Job Description (what will you be doing at this site?)

Job Description (what will you be doing at this site?)

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40. Learning Objectives (list at least two skills or competencies you would like to develop during this experience)

Learning Objectives (list at least two skills or competencies you would like to develop during this experience)

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41. Approval
By selecting "Yes" below you affirm, and agree to, the "Guidelines and Policies" and the "Student Internship Agreement" as shown in the student information section of the Internship Center webpages.

Approval By selecting "Yes" below you affirm, and agree to, the "Guidelines and Policies" and the "Student Internship Agreement" as shown in the student information section of the Internship Center webpages. Yes

No

1) Your academic advisor will be notified by email for their approval of this learning experience.
2) An email will be sent to the Registrar's Office to register you for the credit option you have chosen above.
3) When finished, click the "Submit" button.

42. ------------ For Internship Center Use Only ------------

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Date Entered

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