1. WINTER 2015 INTERNSHIPS

2.  Info packet & required forms are on my website:  www.wou.edu/~robertsjl, then click on Internships link www.wou.edu/~robertsjl EXERCISE SCIENCECOMMUNITY HEALTH EDUCATION 120 hours required (12 hrs/week)240 hours required (24 hrs/week) Terms runs from January 5 th – March 13 th. Hours cannot be started until January 5th and forms MUST be received on January 6th. If forms are late, hours may NOT be counted until forms are received.

3.  Once you identify a site – it needs to be approved by me.  Complete Forms A, B & C  Salem Hospital and Samaritan Health Services do NOT need Form A – everyone else does!  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.

4. 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 _____. For Experience Provider:For WOU: Name: Supervisor’s nameName: Janet Roberts Address:Address: 345 N. Monmouth Ave Telephone:Telephone: (503) 838-8446 Email:Email: robertsjl@wou.edu  Make sure ALL blanks are filled in  The Experience Provider = the name of the company where you will be interning.

5. Form A – Master Agreement page 2 Experience Provider:Western Oregon University: By: (Signature)By: I will sign Name: Print supervisor’s nameName: I will print my name Date:

6. Form B – Student Agreement Student Name: Your name Internship Start Date: 1/5/2015 End Date: 3/13/2015 Department and Course Number: Either HE419 or PE419 Quarter Enrolled: WinterYear: 2015Credit 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

7. 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)  You will need to meet with your site supervisor before you start your internship to determine objectives.

8. Forms  Experience Provider = Internship Site  On form A; for WOU = my name / contact info  KEEP a copy of form C for your records.

9. Upcoming Meetings  Meetings are MANDATORY!!  Tuesday, January 6th, 4pm, location to be determined  Midterm check-in – individual meeting  Wednesday, March 18th, 12noon, location to be determined

10.  Check WOU email regularly  HE419 – CRN 20996 – 8 credits – A-F  PE419 – CRN 21081 – 4 credits – A-F