Internship / Practicum Agreement, Southeast Missouri State University


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Internship / Practicum Agreement

Student’s Name:
SE ID (S0#######):
Option in Major:
Total Hours Completed
Total Hours Completed in Option Sequence

Campus Address
Campus Phone

Cooperating Agency Information

Company Name
Company Address
Supervisor
Resume on File
Title
Phone Number
Internship/Practicum Title for Permanent Records
Starting Date of Internship/Practicum
Closing Date of Internship/Practicum
Number of Weeks of Internship/Practicum

List of Internship/Practicum Work Tasks:

Additional Requirements to be fulfilled before credit is granted for internship/practicum:

Weekly Time Log to be submitted via email at the end of each weekly period as shown on Sample Logs link, totaling 180 hours worth of work
Two on-job work samples representing the internship/practicum (can be in draft form).
Supervisor’s Internship/Practicum Performance Review Form
Self & Program Evaluation Form

All materials and information submitted for your Internship/Practicum become property of the Department of Mass Media to be maintained in the Resource Room. These items cannot be returned.

Student’s Signature
____________________________________________ Date _________________________

Company Representative’s Signature
____________________________________________ Date _________________________

Internship/Practicum Coordinator's Signature
____________________________________________ Date _________________________

Department Chair’s Signature
____________________________________________ Date _________________________