Site Supervisor Verification Form-Spring 2023

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Internship / Independent Study

Email *

Directions: Please complete this brief form and read the included UMCP COCID-19 Practicum and Outside Internships Expectations information provided to verify you will be supervising a student from UMD Department of Kinesiology for an internship or independent study/ research experience. Form must be submitted, no later than the beginning of schedule adjustment period for the corresponding semester.

If you have questions, please feel free to contact one of the KNES Internships Coordinators: Dr. Betty Brown - ebrown2@umd.edu (301) 405-2503 or Dr. Joanne Klossner - jklossne@umd.edu (301) 405-2569

Date *

YYYY

What is the last name of the student intern from UMD Department of Kinesiology that you will supervise? *

What is the first name of the student intern that you will supervise? *

Your name and credentials (if relevant) *

Name of Organization / Site Name *

What is your phone number? *

What is your email address? *

Site Address (including general site email) *

Students register for credit hour hours based on contact hours with the internship/ independent study). Approximately how many internship hours will the student complete under your supervision? *

45 contact hours (1 credit)

90 contact hours (2 credits)

135 contact hours (3 credits)

Unsure at this time

Please BRIEFLY list general duties and expectations of the student while participating in this internship. If repeated internship for the student, please verify that duties will expand about student's previous experience. *

May we save information about this internship in our student internship database? *

Yes, you may include my contact information as well as internship site details

Yes, you may include internship site details only. Please don't include my contact information.

Not at this time.

Thank you for completing this form. By selecting "Yes" below and submitting this form, you will be verifying that the above named student will be completing an internship under your supervision. We appreciate your willingness to provide this professional development opportunity for a Department of Kinesiology student from the University of Maryland! *

YES

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of University of Maryland, College Park. Report Abuse

Forms