Spring 2017 Internships

COMMUNITY HEALTH EDUCATION Info packet & required forms are on my website: www.wou.edu/~robertsjl, then click on Internships link EXERCISE SCIENCE COMMUNITY HEALTH EDUCATION 120 hours required (12 hrs/week) 240 hours required (24 hrs/week) Terms runs from April 3rd – June 9th, 2017. Hours cannot be started until April 3rd and forms MUST be received on April 4th. If forms are late, hours may NOT be counted until forms are received.

Forms due at next meeting. You should already have a placement by now….. The site must be approved by appropriate internship coordinator. Ada Massa Gonzalez for EXS / Janet Roberts for CHE Complete forms B & C See Internship Coordinator regarding form A TYPED except for signatures Handwritten forms will NOT be accepted. Incomplete forms Points will be deducted for incomplete or inaccurate information. Forms due at next meeting.

Form A – Master Agreement (if applicable) This agreement is entered into this ___ day of ___ 20__ (“Effective Date” between Western Oregon University (WOU), an Oregon non-profit cooperation and education institution (WOU), and ____ (The “Experience Provider”) located at _____. First line example: 20th day of April 2015 _______ (The “Experience Provider”) = company name NOT person’s name Example: PTNorthwest; Marion-Polk Food Share; etc Located at __________ = physical address (street address, city, state, zip) Example: 345 N. Monmouth Ave, Monmouth, OR 97361 Make sure ALL blanks are filled in The Experience Provider = the name of the company where you will be interning.

Form A continued – Page 1 For Experience Provider: For WOU: Name: Name: Ada Massa Gonzalez or Janet Roberts Address: Address: 345 N. Monmouth Ave Telephone: Telephone: (503) 838- 9290 or (503) 838-8446 Email: Email: massagonzalez@wou.edu or robertsjl@wou.edu Note: For Experience Provider, this information will be supervisor’s name and information; however, signature on 2nd page needs to be the person who can legally sign contracts.

Form A – Master Agreement page 2 Experience Provider: Western Oregon University: By: (Signature) By: Internship Coordinator signs Name: Print name Name: Internship Coordinator prints name Date: Date: Note: Experience Provider’s signature here will be whoever at the organization may legally sign contracts.

Form B – Student Agreement Student Name: Your name Internship Start Date: 4/3/2017 End Date: 6/9/2017 Department and Course Number: Either HE419 or EXS419 Quarter Enrolled: Spring Year: 2017 Credit Hours: 8/4 Internship Site (“Experience Provider”): Internship Company Name Complete Internship Address: Street #, Street, City, State, Zip Site Supervisor: Supervisor’s first and last name Phone: Supervisor’s phone# Email: Supervisor’s email

Form C - Objectives Fill out the top of the form Do NOT hand forms to your site supervisor to fill out! Objectives need to be TYPED and in correct format (see instructions) “To research fall prevention programs by July 15th, 2015.” To assist with 3 new patient assessments by June 1st, 2017” Personal versus Agency objectives

Form C continued You will need to meet with your site supervisor before you start your internship to determine objectives. KEEP a copy of form C for your records.

Upcoming Meetings Meetings are MANDATORY!! Tuesday, April 4th, 4pm, location TBA (we will email)

Check WOU email regularly HE419 – CRN 31035 – 8 credits – A-F EXS419 – CRN 31029 – 4 credits – A-F