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. ID#

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

10. Campus Address

Campus Address

11. Campus Phone

Campus Phone

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

Cell Phone (be sure to include area code)

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)

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15. Date of Graduation

Date of Graduation

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16. Major

Major

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17. Academic Advisor (last name, first name)

Academic Advisor (last name, first name)

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18. 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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19. I am registering for:

I am registering for:

Professional Development Experiences are graded Pass/Fail.

A Professional Development Experience does NOT substitute for departmental practicum credit.

You must select credits for one of the following two choices listed below - INT291 or INT391.

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20. Course Registration

Course Registration INT391 (juniors/seniors) - 1 credit - minimum 40 hours at site

INT391 (juniors/seniors) - 2 credits - minimum 80 hours at site

INT391 (juniors/seniors) - 3 credits - minimum 120 hours at site

INT291 (sophomores) - 1 credit - minimum 40 hours at site

INT291 (sophomores) - 2 credits - minimum 80 hours at site

INT291 (sophomores) - 3 credits - minimum 120 hours at site

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21. Name of Organization

Name of Organization

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22. Organization Address

Organization Address

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23. Organization City

Organization City

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24. Organization State

Organization State

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25. Organization Zip

Organization Zip

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26. Organization Supervisor

Organization Supervisor

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27. Supervisor Title

Supervisor Title

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28. Supervisor Phone

Supervisor Phone

29. Supervisor Fax

Supervisor Fax

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

Supervisor Email (we must have a valid email address)

31. Organization Website

Organization Website

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

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

33. 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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34. Hours per week

Hours per week

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35. Start Date (e.g. - 9/12/06)

Start Date (e.g. - 9/12/06)

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36. End Date (e.g. - 12/7/06)

End Date (e.g. - 12/7/06)

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37. Total Weeks You Will Be Working

Total Weeks You Will Be Working

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

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

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39. Learning Objective (list at least one skill or competency you would like to develop during this experience)

Learning Objective (list at least one skill or competency you would like to develop during this experience)

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40. Approval
By selecting "Yes" below you affirm, and agree to, the "Guidelines and Policies" and the "Student PDE 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 PDE 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.

------------ For Internship Center Use Only ------------

Date / Time Received _________________________

Initials of Person Entering Data _________

Date Registrar Emailed ___________________