Internships & Occupational Work Experience Online Student Data Form

Students wishing to enroll in Internships (292) and Occupational Work Experience (299) must have an internship placement or job and are required to complete the online student data form before receiving enrollment information. 

By completing this form I authorize my faculty mentor to speak to my worksite supervisor regarding my participation/progress in the Internship/Occupational Co-op.

Personal Information

First Name
Last Name
Student ID
Cell Phone
Alternate Phone
Best Time to Call	Mornings Afternoons Evenings
Day(s) of the Week	Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays
Email
Address
City
State
Zip code
Declared Major or Desired Career Goal	-- SELECT A MAJOR -- Administration of Justice Art Automotive Technology Biology/Biotechnology Accounting Business Administration Real Estate Business/Medical Office Technology Chemistry Child Development/Education Communication Studies Computer Programming/Networking Computer & Web Applications Dance Architecture/Drafting/Engineering History/Political Science Horticulture Hospitality International Languages Health Kinesiology Nutrition English Library Mathematics Media Arts and Technologies Music/Recording Arts Nursing Surgical Technology Philosophy Energy Technology Physical Sciences Psychology Anthropology Economics Geography Sociology Drama Film Undecided
Enrolling in Internship or Co-op	InternshipCo-Op
Are you new or are you returning to Internship or Co-Op?	NewReturning
If returning, list faculty mentor

 

Worksite Information

My Position is:	PaidNon-Paid
Company Name
Company Address
City
State
Zip code
Supervisor's First and Last Name
Supervisor's Phone
Supervisor's Email
Your Position

What would you like to learn or improve in your internship or Occupational Work Experience?
  Days/Hours You Work: (example 3:30-11:00 pm)

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

My Schedule Varies YesNo Internships & Co-op must complete specific hours at the job site by the end of the semester to earn college credit. Students who do not complete the hour requirement will not receive a passing grade in the course. Please select how many credits you wish to complete based on your internship/work schedule. If you have questions or need assistance with credit requirements, please call 760-757-2121 x6575. Non-Paid: 60 Hours = 1 credit
Non-Paid: 120 Hours = 2 credits
Non-Paid: 180 Hours = 3 credits
Paid: 75 Hours = 1 credit
Paid: 150 Hours = 2 credits
Paid: 225 Hours = 3 credits
Paid: 300 Hours = 4 credits (Occupational Co-op Only)

Please give specific directions from the college to your place of employment.

Is there a receptionist?	YesNo
Is there a security guard?	YesNo
Is parking an issue?	YesNo

Questions/Comments?

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