Internship Agreement Form
To verify your internship experience for academic credit, please complete the information below to submit directly to the Internship Program Director. Once approved, the Internship Director will issue you the permission number for internship course registration.

Please note: The information you provide on this form will help you to complete your required internship coursework.

Student name
Your answer
Student ID
Your answer
Term of internship
Ex. Fall 2020
Your answer
Academic major
Your answer
LSBE Internship Progam: Variable Credit Option
As of Fall 2016, the LSBE Internship Program offers a variable credit option for students seeking to enroll in internship course for credit. The goal is to provide students the opportunity to complete more than one internship during their educational experience. The internship course is repeatable for up to 3 times with a maximum of 6 credits earned.

For majors that allow for only three (or fewer) credit hours of internship in the “major curriculum,” students will be allowed to count the remaining internship credits in the Upper Division Supporting Courses category.

Please visit the website for the complete list of policies associated with the credit variable option at

Are you hoping to earn academic credit?
How many credits are you hoping to register for?
LSBE Faculty Advisor
Your answer
Internship position title
Your answer
Is your internship paid or unpaid?
Organization name
Your answer
Your answer
Employer Site Supervisor or HR Contact
Your answer
Employer email
Your answer
Have you communicated with your employer regarding your pursuit of academic credit for your internship?
We communicate with your site supervisor prior to the start of the semester of your internship. Please check the appropriate box.
Internship Job Description
Provide a list of the duties and responsibilities you will be performing during your internship.
Copying and pasting a job description is acceptable. Your responsibilities are not limited to what you list.
Your answer
Draft of Learning Objectives
Learning objectives provide you and your employer supervisor a guiding framework to your internship experience. Your final learning objectives will be submitted during the internship course. The information you provide is is a rough draft/ ideas of what goals you hope to achieve.
During the internship course, you will complete an assignment outlining 4 learning objectives. These objectives fall within the following 3 categories: Knowledge related to your major( required), skill development ( required), personal development.

Learning objectives guidelines:
• How does this experience relate to my major and career interests?
• “What will I be able to do as a result of this internship experience?”
• Will this experience support your academic, professional and personal growth?
• Are these goals mutually agreed upon between you and the employer site supervisor?

Knowledge related to your major
Your answer
Skill Development
Your answer
Personal Development
Your answer
Supervision & Feedback
Supervisors are expected to provide an evaluation at the end of the internship and feedback throughout the internship.Students should also receive supervision in their internship experience. At the end of the internship course, an employer evaluation will be sent by the Internship Program Director.
Can you provide some information on how you will be supervised?
Your answer
Never submit passwords through Google Forms.
This form was created inside of University of Minnesota Duluth. Report Abuse - Terms of Service - Additional Terms