Winter 2017 Internships

COMMUNITY HEALTH EDUCATION Info packet & required forms are on the 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 Jan 9th – March 17th. Hours cannot be started until Jan 9th and forms MUST be received on Jan 10th. If forms are late, hours may NOT be counted until forms are received.

Complete Forms A (if applicable)**, B & C Once you identify a site – it must be approved by appropriate internship coordinator. Ada Massa Gonzalez for EXS / Janet Roberts for CHE Complete Forms A (if applicable)**, B & C **See Internship Coordinator regarding Form A. TYPED except for signatures Handwritten forms will NOT be accepted Incomplete forms – 5 points will be deducted from final grade for each incomplete form. Completed forms are due at next meeting.

Form A – Master Agreement 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 Located at __________ = physical address (street address, city, state, zip) 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: Janet Roberts / Ada Massa Gonzalez Address: Address: 345 N. Monmouth Ave Telephone: Telephone: (503) 838-8446 / (503) 838-9290 Email: Email: robertsjl@wou.edu / massagonzaleza@wou.edu NOTE: For Experience Provider: name may or may not be supervisor’s name it might be legal representation of the company or human resources director, etc.

Form A – Master Agreement page 2 Experience Provider: Western Oregon University: By: (Signature) By: WOU internship coordinator Name: Print name Name: WOU internship coordinator Date: Date:

Form B – Student Agreement Student Name: Your name Internship Start Date: 1/9/2017 End Date: 3/17/2017 Department and Course Number: Either HE419 or EXS419 Quarter Enrolled: Winter 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 in internship packet) “To research fall prevention programs by July 15th, 2015.”

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, Jan 10th, 4pm, location TBD (email will be sent out a few days before meeting with location)

Check WOU email regularly HE419 – CRN 20745 – 8 credits – A-F EXS419 – CRN 20494 – 4 credits – A-F