Jepson School Internship Confirmation Form

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Jepson juniors completing their credit-bearing internship need to complete and submit this form once they secure their internship. Ideally, this should be submitted by the final examination date for a student's section of LDST 488 in the spring. If an internship is secured after the spring semester, this form should be completed and submitted immediately once the internship is secured.

Student's First name *

Student's Last Name *

Name of Internship Site: *

City and State of Internship Site *

Anticipated Start Date (month, day, year) *

YYYY

Anticipated End Date (month, date, year) *

YYYY

Anticipated Hours Per Week *

Is your internship *

In Person

Remote

Hybrid (some in person and some remote)

Brief Description of Role/Responsibilities *

Site Contact Person (first and last name) - NOTE: this may or may not be your designated supervisor. If you know your designated supervisor, list that individual. *

Title of Site Contact Person *

Email for Site Contact Person *

Phone number for Site Contact Person *

Submit

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