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
Day(s) of the Week





Email  
Address  
City  
State  
Zip code  
Declared Major or Desired Career Goal
 
Enrolling in Internship or Co-op
Are you new or are you returning to Internship or Co-Op?
If returning, list faculty mentor

Worksite Information

My Position is:
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
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.





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

Is there a receptionist?
Is there a security guard?
Is parking an issue?
Questions/Comments?
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