Advisor Sponsored Internship Proposal

To register for an Academic Advisor sponsored internship, please 1. Complete this form and return to the Psychology building, room 312 with all required signatures.2. If approved, an Academic Advisor will enroll you in the units. You will be contacted if a Change of Schedule form is necessary.3. Please allow 3-5 business days for processing.NOTE: If you are an international student, there is additional paperwork that must be completed before completing this packet.Please visit https://global.arizona.edu/international-students/curricular-practical-training-cpt or contact an International StudentServices advisor.

Student Information

First Name

Last Name

Email

SID# Phone #

Registration Information

Internship Course # 393 Year Semester

The University Board of Regents have set a standard for 45 hours of work per unit earned. (1 unit = 45 hrs, 2 units = 90 hrs, etc.)

Explanation (please include total # of units you want

to earn here)

Internship Details

Duration (start & end dates)

Hours Per Week Expected

Relation to Psychology

Please explain, in detail, how this internship is related to Psychology.

NOTE: This experience cannot be strictly clerical.

to

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# of units Class Standing

@email.arizona.edu

Agency Details

Agency Name

Agency Physical Address

Agency Phone # Agency website

Agency/Site Supervisor Details

Supervisor Name

Title Phone

Email address

Student Learning Objectives (please list your primary objectives for participating in this internship experience. You may work on these independently or with your agency supervisor. Not all 4 spaces are required.)

Objective 1:

Objective 2:

Objective 3:

Objective 4:

Engaged Learning

This Course is an Engaged Learning course in which you will participate in significant experiential learning and reflection designed to prepare you to apply skills and knowledge to the types of problems you may encounter beyond the classroom. If you earn a grade of P, or S, you will earn the notation “Engaged Learning Experience: Completed” on your UA transcript. The completion of this course will also appear on your Student Engagement Record in UAccess. Be sure to talk with your departmental sponsor to discuss the final reflective report.

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1. Recognize that you are representing The University of Arizona and the Department of Psychology as an ambassador tothe community and abide by the Student Code of Conduct and Code of Academic Integrity.2. Recognize and agree that neither the Academic Advisor sponsoring you nor the Department will be responsible forany financial obligations incurred by your participation in this internship experience; this includes, but is not limited to,travel, transportation, fingerprint cards, background checks, etc.3. Neither the Academic Advisor nor the University will be liable for or responsible for the payment of any medical carefor injuries alleged to have resulted from your internship experience.4. Be prepared to perform your internship duties for the hours and duration specified.5. Fulfill all of the academic assignments and reporting requirements of the internship course as specified by thedepartment in order for a grade to be assigned.6. Notify the Sponsoring Organization and the course instructor two weeks prior to the end of the internship.

By signing below, all parties affirm that they have read, agreed to, and understood their responsibilities and obligations set forth above as well as those set forth in the University of Arizona's Internship Policies and Guidelines http://registrar.arizona.edu/forms/registrar-forms?audience=faculty&cat1=14&cat2=253

Internship Site Supervisor Signature

Date

Student Signature Date

Dept. Sponsor Signature

Date

Participation Agreements for You, the Student:

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University of Arizona Internship ASSUMPTION OF RISK AND RELEASE FORM

THIS IS A RELEASE OF LEGAL RIGHTS -- READ AND UNDERSTAND BEFORE SIGNING (If student is under 18 years of age, a parent or legal guardian must also read and sign this form)

Student Participant: __________________________________________Date of Birth:

Student ID: _____________________

Internship Course: Sponsoring Organization:

I hereby agree as follows:

RISKS OF PARTICIPATION

I recognize that there are dangers and risks to which I may be exposed by participating in this internship. The following is a description and examples of specific, significant, non-obvious dangers and risks associated with the internship, as explained by the on-site supervisor:

__________________________________________________________________________________________

__________________________________________________________________________________________

I understand that the University of Arizona (the “University”) does not require me to participate in the internship, but I want to do so, despite the possible dangers and risks and despite this Release.

I therefore agree to assume all of the risks and responsibilities that are in any way associated with the internship.

HEALTH & SAFETY

I understand and agree that the University and its governing board, administrators, and employees (the “Releasees”) do not have medical personnel available at the Sponsoring Organization, which is the site location for my internship. I understand and agree that the Releasees are granted permission to authorize emergency medical treatment, if necessary, and that such action by the Releasees shall be subject to the terms of this Agreement. I understand and agree that the Releasees assume no responsibility for any injury, damage or cost which might arise out of or in connection with such authorized emergency medical treatment.

I have consulted with a medical doctor with regard to my personal medical needs. There are no health-related reasons or problems that preclude or restrict my participation in this internship. I have arranged, through medical insurance or otherwise, to meet any and all needs for payment of medical costs while I participate in the internship.

I understand that neither the Releasees nor the Sponsoring Organization are obligated to provide transportation in connection with the internship. I understand that I am expected to carry my own automobile liability insurance coverage.

STANDARDS OF CONDUCT

I will comply with the University's Student Code of Conduct and Code of Academic Integrity, as well as the standards of conduct for employees of the Sponsoring Organization. I waive and release all claims against the

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University that arise at a time when I am not under the direct supervision of the University or that are caused by my failure to remain under such supervision or to comply with such codes and academic standards.

I agree that the University has the right to enforce the standards of conduct described at: http://studpubs.web.arizona.edu/policies/cofc.htm, as well as at: http://studpubs.web.arizona.edu/policies/cacaint.htm, and that the University will impose sanctions, up to and including expulsion from the internship or from the University, for violating these standards or for any behavior detrimental to or incompatible with the interest, harmony, and welfare of the University, the department’s internship program, the Sponsoring Organization, or other student participants.

The University has the right to make changes in the format and administration of the internship. I understand that the University has no control over the operations or premises of the Sponsoring Organization, and that I will be under the supervision of a representative of that organization while I am participating at the internship.

ASSUMPTION OF RISK AND RELEASE OF CLAIMS

Knowing the risks described above, and in consideration of being permitted to participate in the internship, I agree, on behalf of my family, heirs, and personal representative(s), to assume all the risks and responsibilities surrounding my participation in the internship. To the maximum extent permitted by law, I release and indemnify the Releasees from and against any present or future claim, loss or liability for injury to person or property which I may suffer, or for which I may be liable to any other person, during my participation in the internship (including periods in transit).

I have carefully read this Release Form before signing it. No representations, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. This agreement shall become effective only upon receipt by the University of Arizona in the Department of __________________________________ and shall be governed by the laws of the state of Arizona, which shall be the forum for any lawsuits filed under or incident to this agreement or to the internship.

Signature of Student Participant Date

Psychology

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