LETTER OF AGREEMENT

Principle objectives of the internship program are to:

• Provide an opportunity for the intern to refine the National Commission for Health Education Creditialing’s  (NCHEC) Areas of Responsibility and Competencies in community health education.
• Provide a gradual transition from the college setting to the professional or community setting.

Details regarding the responsibilities of the students, site supervisors and internship coordinator can be found in the internship manual.

Student’s objectives: (staple typed copy of objectives behind this page)

Idea for final project:

Timeline:                     Beginning date of internship:   ____________________

                                                                                                mo.      day      yr

                                    Ending date of internship:        ____________________

                                                                                                mo.      day      yr

Work Schedule (list days, hours intern will be scheduled to work):

Agency Name:             _______________________ Phone #:                      __________________

Address:           _______________________  Supervisor’s name:      __________________            _______________________ Supervisor’s signature:__________________

Today’s Date:  _______________________ 

Student’s name: _______________________            Home Phone #:            __________________

Signature:        _______________________  Intern Phone #:            __________________

Address:           _______________________

                        _______________________ Number of credits intern is registered for:  ___

Today’s Date:  _______________________

UMD intern coordinator:         Dr. Ladona Tornabene

Phone #:                                  218.726.7522

Fax:                                         218.726.6243  

Address:                                   1216 Ordean Ct.110 SpHC

Duluth, MN 55812

email:                                       ltornabe@d.umn.edu

Signature                                 _______________________

Today’s Date:                          _______________________

THIS  ORIGINAL FORM  MUST  BE  FILLED  OUT, SIGNED  AND  RETURNED TO  UMD INTERN  COORDINATOR  PRIOR  TO  BEGINNING INTERNSHIP. 

A copy should be retained for student and site supervisor’s records.