Faculty-Led Education Abroad New Program Proposal Form

PleaseconsulttheonlineFaculty-ledEducationAbroadGuideforProposalWritingpriortocompletingthisform.FurtherassistancemaybeobtainedbycontactingtheAssociateViceChancellorforOIEDat828-262-2046.

ThefollowingpeoplearerequiredtocontactOIEDtoarrangeforamandatorypre-proposalconsultationwithOIEDtopreventdelaysintheapprovalprocess:First-timeprogramleadersforanytypeofprogram;experiencedprogramleadersdevelopinganewprogram.

SubmitthecompletedproposalandattachmentsviaemailtoMarkHagenathagenm@appstate.edu,andprovideapapercopythatincludestheapprovingsignatures.TheproposalwillbereviewedbytheFaculty-ledEducationAbroadProgramsCommitteebeforeobtainingfinalapprovalbytheAssociateViceChancellorforInternationalEducationandDevelopment.

PleasenotethattheFaculty-ledEducationAbroadProgramsCommittee,theDirectororAssistantDirectorofEducationAbroad,ortheAssociateViceChancellorforOIEDmayrequireadditionaldocumentationpriortoapprovingaproposal.

ProgramName

Countries

Duration Departure Return TotalDays

LastName FirstNameProgramLeaderAssociate1

Associate2

Term/yearprogramwillbeoffered

Datesforcourse(ifdifferentfromtravel)

NewProposalForm 2

CourseInformation

• FormalContactHours:Eachcredithourrequiredmustinclude15hoursofformalinstructional contact,andapproximately30hoursofinformalclass/studytime.

• Tripswithcoursesenrollingbothundergraduateandgraduatestudents:Besuretoinclude eitherasinglesyllabusthatdocumentsincreasedexpectationsforgraduatestudentsortwo syllabi,includingonthegraduatesyllabusaclearindicationoftheincreasedexpectationsfor graduatestudents.

• Generaleducationcourses:ContactDr.Ted Zerucha,DirectorofGeneralEducationat zeruchat@appstate.edu,preferablybeforeyoufilloutthisprogramproposalform.Formore informationonhowtoapplyforGeneralEducationcredit,pleasevisit:generaleducation.appstate.edu/general-education-study-abroad.

• Civicengagementcourses:Studyabroadprogramswithaservice-learningcomponentmay qualifyasacivicengagementcourse.Ifinterested,pleasesubmityoursyllabustoDr.Brian MacHargatmachargbd@appstate.edu.Thismaybecompletedafterprogramapproval.For moreinformation,pleasevisit:engagement.appstate.edu/course-materials.

Areyouplanningonenrollingstudentsataforeignhostinstitution?Yes,institutionname: NoDoesthehostinstitutionhaveanagreementwithAppState? Yes No

Areyouplanningoncollaboratingwithaforeignhostinstitution(noenrollment)?Yes,institutionname: NoDoesthehostinstitutionhaveanagreementwithAppState? Yes No

Checkallofthecomponentsbelowandprovideabriefdescription:CommunityserviceCivicEngagementResearchwithhumanoranimalsubjects

NewProposalForm 3

Course(s).Pleasecompletebothsections.

U/G CourseName CoursePrefix,NumberandSection

CreditHours

FormalContactHours

InformalContactHours

Instructor(s)

CourseInformation(checkallthatapply)

Isthiscourserequiredforthestudyabroad?*

Doescoursesatisfyamajor

requirement?

Doescoursesatisfyaminor

requirement?

QualifiesforGenEd? Othernotes?

*Ifastudentisrequiredtotakethiscourseinordertoparticipateinthestudyabroadexperience,pleaseindicatehere.

Minimumnumberofrequiredcreditstoparticipateinthisprogram?Maximumnumberofcredits?

NewProposalForm 4

Listcourse/programprerequisites.

Listlanguagerequirementsforthisprogramandhowstudentwillmeettheserequirements.Ifnone,pleasedescribehowstudentswillhandlebasiclanguageneedsincountry.

Brieflydescribetheprogramofactivities,opportunitiesforlanguageand/orcross-cultural

immersion,sideexcursionsrelatedtothecourse,visitstorelevantin-countryinstitutionsand

organizations.

NewProposalForm 5

ProgramLeaderBiographicalInformationandQualifications

ProgramLeaderLast First

emailAppState Other

Phone

Office Cell

College

College Department

Officelocation

Building/Roomnumber

Emergency

contact(optional)

Name/Relationship Phone

Describeyourinternationaltravelandteachingexperiencewithstudentgroups.

Describeyourtravelexperienceintheproposedprogramlocation(s).Ifyouhavenoexperienceinthelocation,pleaseindicatehowyouwillacquiretherelevantinformationtosucceedbothacademicallyandlogisticallyforthisprogram.Iftravelingtoanon-Englishspeakingcountryorarea,pleaseincludeyourleveloffluencywiththelocallanguage.

NewProposalForm 6

AssociateLeaderBiographicalInformationandQualifications.Ifnoassociateleader,skiptonextpage.

ProgramLeaderLast First

emailAppState Other

Phone

Office Cell

College

College Department

Officelocation

Building/Roomnumber

Emergency

contact(optional)

Name/Relationship Phone

Describeyourinternationaltravelandteachingexperiencewithstudentgroups.Describeyourtravelexperienceintheproposedprogramlocation(s).Ifyouhavenoexperienceinthelocation,pleaseindicatehowyouwillacquiretherelevantinformationtosucceedbothacademicallyandlogisticallyforthisprogram.Iftravelingtoanon-Englishspeakingcountryorarea,pleaseincludeyourleveloffluencywiththelocallanguage.

NewProposalForm 7

Ifyoudonothaveanassociateleader,pleaseexplainwhowillassistinemergencies.Allproposalapplicants:ifyouhavesomeonein-countrywhowillbeassistingwitharrangements,

pleasedescribetheirqualifications.

New Proposal Form 8

Short-term Faculty-led Education Abroad Programs

Salary Parameters – Repeat Programs

Important:

Faculty leaders from the College of Arts and Sciences need to complete the “Study Abroad Salary Form” found on the Faculty-led Proposals webpage.

Note: Please complete a separate form for each faculty leader who will be paid during the program.

For Summer Session Programs For Fall/Spring Programs

Please check below the box that corresponds to your proposal:

New summer session program expected to generate the equivalent of approximately 12 student tuition payments*

This program is offered during the semester.

It requires faculty stipend(s) of $1000 each.

Repeat summer session program expected to generate the equivalent of approximately 15 student tuition payments*

*If projected enrollment numbers are not met, programleaders are required to renegotiate their summer schoolsalary with the Dean’s office.

Fee generated program derived from an enrollment in credit hours.

Approvals (please obtain approvals from the same signatories on the repeat proposal form)

____________________________________________________ ____________________

Signature of Program Leader Date

____________________________________________________ ____________________

Signature of Department Chair Date

____________________________________________________ ____________________

Signature of College Dean Date

____________________________________________________ ____________________

Signature of Dean of the Graduate School Date

NewProposalForm 9

UnofficialTravelers

Allunofficialtravelersmustpayairfare,anypercapitacostsforfood,lodging,plusanyprogrammingcostsincurred.Aspouseordependentoftheprogramleaderorassociate(s)isconsideredanunofficialtraveleraffiliatedwithAppalachian.AnyoneNOTaffiliatedwithAppalachianmustsignanAssumptionofRiskandIndemnityAgreementbeforebeingallowedtoparticipate.Namesofallunofficialtravelers AffiliatedwithASU Yes No Yes No Yes No Yes No

New Proposal Form 10

Logistical Arrangements

If applicable, provide the names and webpages of all vendors that will coordinate in-country arrangements. Note that all contracts with vendors must be signed and approved by the University administration, not individual faculty or staff. Important: all lodging other than hotels may require

additional approval. Please contact OIED for additional information prior to submitting proposal.

Lodging (check all that apply and provide a brief description of arrangements).

Hotel Hostel Student Residence Hall Home Stay Other (must describe) Describe classroom or other teaching venues.

Describe arrangements for meals, indicating what is covered by the cost of the program. Please be specific about how meals will be paid (e.g., per diem paid to students, group meals paid by leaders, students pay for some/all meals on their own, etc.).

NewProposalForm 11

AirTransportation

Included NotIncludedDeparturecity(whereprogrambeginsandends) _______________________________________Overseasarrivalcity _______________________________________Overseasdeparturecity _______________________________________Listintermediaryflights(city,countrytocity,country): _______________________________________Describein-countrytransportation.

NewProposalForm 12

ProgramLocationSafetyAssessment

ReviewtheCentersforDiseaseControlandPreventionwebsite(wwwnc.cdc.gov/travel/),theU.S.DepartmentofStatewebsite(travel.state.gov),andOverseasSecurityAdvisoryCouncil(OSAC)(www.osac.gov)forthelocationsandroadtravelincludedinyourprogram.Areanyissuesrelatedtoprogramlocation,saferoadtravel,cleanwateraccess,medicaladvisories,etc.,listedintheseresources?Ifso,provideasummaryoftheinformationhere.

SafetyofLocation(s),Housing,andMeals

Describeanypotentialsecurity/safetyconcernsaboutthecountries/towns/generallocationsproposedforyourprogram.

Describeanypotentialsafetyconcernswiththelivingarrangementsandstudylocation.Alsodiscussanylocationsneartheprogramsitethatareconsideredunsafeandwherestudentswillnotbeallowedtogo.Ifusinghomestays,pleasedescribehowtheyarevetted.

NewProposalForm 13

Describeanypotentialconcernsrelatedtothesafetyofgroupmeals,individualmeals,cleanwater,etc.SafetyofTransportation

Ifstudentsarearrivingindependentlyto/fromtheinternationalairport,addresshowyouwillplantohandledifferingarrivalsandtheirsafetraveltotheprogramsite.Checkallthatapply,anddescribelevelofsafetyandsafeguardsinplaceforeach. Publictransportation(train,taxi,metro,etc.) Charteredbuses/vans VehiclesdrivenbyAppalachianemployees(requiresspecialpermission*) Extendedtravelonfoot

NewProposalForm 14

*DoyouplanforanyAppalachianemployeestodrive?Ifso,who?YouwillneedtocheckthedrivingrequirementsincountryandrequestapriorapprovalthroughOIEDbysubmittingaphotocopyofthedrivinglicense(s)tobecheckedbyUniversityPoliceatleastthreemonthspriortodeparture.StudentsarenotallowedtodriveunlesstheyareundercontractwithAppalachianStateUniversityandtheirdrivingrecordshavebeenchecked.ASUDrivers Indicatefaculty,staff,orstudent HealthandMedicalAccessYouarestronglyencouragedtocontacttheTravelServicesNurseatASUStudentHealthServiceandincorporateyourfindingsbelow.Youmustalsoconsultthefollowingwebsitesforadditionalhealthinformation:

• CentersforDiseaseControlandPrevention(wwwnc.cdc.gov/travel/destinations/list/)• U.S.StateDepartment(travel.state.gov)• WorldHealthOrganization(www.who.int/countries/en/)

Site-relatedmedicalissues:Pleasespecifyanyimmunizationrequirementsandhealthconcernsrelatedtoyourprogramsite(s),andhowyouplantoaddressthem.Itisimportanttodistinguishmedicalrequirementsfrommedicalrecommendationsandtocommunicatethatdifferencetothestudents.Itisimportanttoreflectintheprogrambudgetthecostforhealthpreparationandtocommunicatetothestudentsinwritingthatthiswillbeanout-of-pocketexpensenotincludedintheprogramcost.

NewProposalForm 15

Studentmedicalfitness:Arethereanyspecificfitnessrequirementsyourstudentsneedtomeetforsuccessfullycompletingyourprogram?Ifso,whatmeasureshaveyoutakentoensurethatthestudentsmeetthoserequirements(screeningprocedureswithAppalachian’sinfirmary,healthforms,etc.)?Medicalfacilities:Describethetypes,location(s)andqualityofmedicalfacilitiesnearyourprogramsite(s).OnceourofficehasenrolledalltheprogramparticipantsintheHTHWorldwidehealthinsuranceplan,youandthestudentswillbeabletolocateEnglish-speakingmedicalstaffandfacilitieslinkedtotheplan.

NewProposalForm 16

ProgramdescriptionfortheOIEDwebpagespecificforyourprogram.(Suggested1,000to2,000

characters).

NewProposalForm 17

Approvals

FORTHEPROGRAMLEADER

MysignaturebelowindicatesthatIagreetoabidebyuniversitypolicyandtheregulationsandproceduresof

theOfficeofInternationalEducationandDevelopment(e.g.,onlineFaculty-ledEducationAbroadProgram

LeaderHandbookandtheAppalachianInternationalCrisisManagementProtocols).

NameofProgramLeader:Pleaseprint

SignatureofProgramLeader:

Date:

FORTHEDEPARTMENTCHAIR(S)ANDCOLLEGEDEAN(S)

MysignaturebelowindicatesthatIapprovethisinternationalexperienceandcertifythattheassociated

academiccourseshaveappropriategoals,objectives,andacademiccontentandareofferedatthe

appropriatelevel.Inadditiontheinstructorofrecordisqualifiedtoteachthecontentandtheprogram

leaderand/orco-leaderisqualifiedtosupervisethestudentswhiletraveling.

NameofDepartmentChair(s):Pleaseprint

Signature(s)ofDepartmentChair(s):

Date:

NameofCollegeDean(s):Pleaseprint

SignatureofCollegeDean(s):

Date:

FORTHEDEANOFTHEGRADUATESCHOOL

MysignaturebelowindicatesthatIcertifythatthegraduatecoursecontentissufficientlyrigorous,andif

dual-listed,thatthereissufficientdistinctionbetweenrequirementsforundergraduatesandgraduate

students.

SignatureoftheDean:

Date:

FORTHEFACULTY-LEDEDUCATIONABROADPROGRAMSCOMMITTEE

Signature:

Date:

FORTHEASSOCIATEVICECHANCELLOROFOIED

Signature:

Date:

NewProposalForm 18

SubmissionChecklist

HardCopySubmissionChecklist

Newproposalform(required)Budget(required)Itinerary(required,seeexampleattached)

Syllabuswithformalandinformalcontacthours(required,seeexampleattached)

GlobalLearningOutcomes(required,seeexampleattached)

Approvalsignaturespage(required)StudentHealthServiceProgramLeaderQuestionnaire(required)DateExceptionformsA&B(asrequired;seeattachedprocedures)ElectronicCopySubmissionChecklist(emailedtoMarkHagenathagenm@appstate.edu)

Saveandsendanelectroniccopyofthisproposalform(required;please,noscans)BudgetinExcelformat(required;please,noscans)Scansofallotherdocumentsfromhardcopylistabove(required)

Updated 1/2016

For Office Use Only Scanned By: Appalachian State University

Student Health ServiceProgram Leader Questionnaire

Date Submitted:

This form must be completed and returned BEFORE you will be able to schedule your Group Meeting with the Travel Nurse

Banner ID #: Program Leader's Name: Address: Telephone: (Cell)

Travel Itinerary A. Travel Specifics: Date of Departure from USA: Date of Return to USA:

Country Region/City Length of Stay 1.

2.

3.

Additional Countries, Side Trips or Regions Being Visited:

B. Purpose of the trip: Pleasure/Tourist Research/Study

Visiting Friends/Relatives Business

Term/Year Abroad Short-Term Faculty Lead

D. Will you be working in the medical or dental field with exposure to blood or body fluids? If so, where will you work and what work will you be doing:

F. What type of accommodations will you be staying in?

Dorm Style Hostel Boat / Ship

Staying on the international hotel circuit Staying and/or eating with local families Other

Camping / Wilderness

G. Are you anticipating any of the following during your trip? None High Altitude Rafting or other water sports

Humanitarian/Mission Trip Peace Corp

/Mtg. Date / Time:

Meeting Location: Bldg Rm

@AppState.edu

C. Activities planned:

(Office) ASU email

Mtg. Length:

Application Deadline for Program Enrollment: Frequency of Classes/Meetings:

Date Class will First Meet: Class Days / Class Hours:

E. Will you be working in a field with exposure to animals? If so, where will you work and what work will you be doing:

Yes No

Yes No

Extreme Sports

Unsanitary Conditions

Refugee Contact Safari

PROCEDUREFORFEAPPROGRAMSOUTSIDETHEREGULARSEMESTERTERMSORPROGRAMSWHERE

STUDENTSWILLMISSSEMESTERCLASSES

PEROFFICEOFTHEPROVOSTFormA:ProceduresforStudyAbroadDuringRegularTermsFormB:ScheduleofClassesAcademicCourseMeetingDatesExceptionForm(fromRegistrar’soffice)Dependingonthedetailsoftheproposedstudyabroad,itmightbenecessarytocompletebothforms.Scenarios:

1) Courseislistedwithinthefallorspringregularsemesterdatesbutrequiresthatstudentsmissamaximumofthreedaysofclassbeforeorafterfall/springbreaks(fallandspringbreakprogramsareencouragedtoreducethenumberofmissedclassdaysasmuchaspossible).FormArequired.

2) Courseislistedasfallorspringsemesterwithtraveloccurringoutsideofnormalbreakperiods(thisoptionnormallyappliesforgraduateprogramswherethestudyabroadcourseisapartofthedegreeprogram).FormArequired.

3) Courseislistedasspringsemesteranddepartsrightaftergraduationbutendsbeforesummer

sessionIstarts.FormBrequired.

4) CourseislistedassummersessionIbutbeginsbeforetheofficialsummersessionIstartdateORislistedasasummersessionIorsummersessionIIcourseandendsafterofficialsummersessionIorIIenddates.FormBrequired.

5) Courseislistedasfallorspringsemesterandleavesbeforegraduationiscompleted.FormsA

andBrequired.(OnlyFirstYearSeminarprogramsareeligibletodepartbeforegraduation)Pleasenote,theseinstructionsandformsapplytobothUndergraduateandGraduatePrograms.

PROCEDUREFORAPPROVALOFSTUDYABROADTRAVELLINGDURINGREGULARSEMESTERTERMS

(FormA)

TheIssue:TheEducationAbroadCommitteereceivesafewrequestseachyearforprogramsthateithergooutsidetypicalbreakperiods,exceedbreaktermdates,oraretravelingduringthemiddleofsemester.Studentsonthoseprogramsmisstheirclassesiftheychoosetoparticipate.Wehavedevelopedaprocesstoensurethatthereisasolidacademicreasonforstudentstomissclasses.Furthermore,thefacultymemberswhoteachthosemissedclassesneedtobecomeawareofthetravelplansinadvanceandarewillingtoworkwiththestudentstominimizetheimpact.*Allprogramsareexpectedtohavestartandenddatesthatallowstudentstobeoncampusforfinalexamsandgraduation.Programsmaybeapprovedtodepartbeforethecompletionofgraduationceremoniesifitcanbeshownintheproposaldocumentsthatfinalsemesterseniorsarenoteligibletoparticipateontheprogram.CurrentlytheonlyprogramsthatareeligibleforthisexemptionareFreshmanYearSeminarprograms.Procedures:1)FacultyLeadersmustcompleteFormAandpossiblyFormBwiththeirinitialprogramproposal.2)FormArequiresajustificationthatexplainswhytheyneedadditionaldaysforthisparticularprogramandwhatthoseadditionaldayswilladdtotheacademicstudentlearningoutcomesofthetrip/course.Itwilloftenbenecessarytoexplainwhythecoursecannotbeofferedcompletelywithinabreakperiod.3)Asupplementalformshouldbecreatedtoconfirmthatstudentsgoingontheprogramhavepriorapprovalofallinstructorstomakeupwork.Itwillbetheresponsibilityofthestudenttodocumentthatapproval.Studentswillnotbeallowedtosignupforastudyabroadexperiencewithoutfirstprovidingthatdocumentationtotherelevantdepartmentchair.TheprogramleaderswillprovidecopiesofthoseformstoOIEDbeforedeparture.(SeeFormA2foranexample)4)Thesupplementalformshouldbeapprovedbythehomecollege(ofthemajor)andthenbyAcademicAffairs.5)Programsthathaveonlyoneadditionaldayaddedon(i.e.leaveontheFridaybeforespringbreak)donotneedtohavestudentscompletethesupplementalapprovalformbutshouldsubmitacompletedFormAwiththeirproposal.

RequesttoOfferaStudyAbroadCourseDuringaRegularTerm

(FormA)TheEducationAbroadProgramCommitteereceivesafewrequestseachyearforprogramsthateithergooutsidetypicalbreakperiods,exceedbreaktermdates,occurduringthemiddleofasemester,orbeginbeforegraduation.Asaresult,studentsonthoseprogramswillmissotherclassesorgraduationiftheychoosetoparticipate.Thepurposeofthisformistoexplaintheacademicreasonsforstudentstomissclassesandtomakesurethatthefacultywhoteachthosemissedclassesareawareofthetravelplansinadvanceandarewillingtoworkwiththestudentstominimizetheimpact.DepartmentorProgramOfferingtheStudyAbroadExperience:________________________________InstructorsTravelingwiththeStudents:___________________________________________________CountryorCountriesWheretheCourseWillBeHeld:________________________________________TravelDates,includingtravelwithintheU.S.:_______________________________________________Whydoesthisstudyabroadexperienceneedtobeofferedduringtheregularacademicterm?Couldthenumberofdaysofmissedclassesbereducedorminimized?Whataretheacademicreasonsforschedulingthestudyabroadexperienceatatimethatconflictswiththeregularclassschedule?Whataretheacademicorprogrammaticreasonsforschedulingthedepartureofthestudyabroadexperiencebeforegraduationceremoniesarecompleted(applicabletoFreshmanYearSeminarprogramsonly)?Bysigningbelow,IamindicatingthatIapproveoftheplandescribedabove.SignatureoftheDepartmentChair:______________________________Date:_________________SignatureoftheDeanorAssociateDean:_________________________Date:_________________SignatureoftheVPforUndergraduate:___________________________Date:_________________Educationand/ortheDeanoftheGraduateSchool

Form A2

The________isofferingastudyabroadexperiencein____thatwilldeparton____andreturnon____.Becauseofthosetraveldates,studentsparticipatinginthisstudyabroadexperiencewillmiss____daysofclass.Thestudentnamedbelowisregisteredforoneofyourclasses.Allsuchstudentsmusthavepriorapprovalfromeachoftheirfacultymembersinordertosignupforthestudyabroadexperience.Bysigningbelowyouareagreeingtoprovidethestudentwithanopportunitytomakeupanymissedwork.Ifyouagreetoallowthisopportunity,pleasesigninthespaceprovided;ifyoudonotagree,pleasewrite“Idonotagree”inthesignaturespace.AcademicAffairsisnotpressuringyoutodecideonewayortheother,butpleaseprovideananswertothisrequestby_____sothatthestudentcaneithertakeanotherclassordecidenottoparticipateinthestudyabroadexperience.Thankyouforconsideringthisstudent’srequest.Bestwishes,Dr.MarkGinn,ViceProvostforUndergraduateEducationStudentName:______________________ Course InstructorName SignatureExample SW1111 Jones

Course1:

Course2:

Course3:

Course4:

Course5:

Course6:

Pleasereturnthiscompletedformto______,Chair,_______.Address:__________________________________________

Office of the Registrar Schedule of Classes Academic Course Meeting Dates Exception Form

All classes at Appalachian State University should have start and end dates based on the standard academic semesters (Fall, Spring and Summer) as determined by the University Calendar Committee. However, some courses may need to meet outside those defined dates for academic reasons, and these may be granted exceptions to the standard scheduling requirement. This form is used to justify exceptions and must be approved by the Dean of the College and Academic Affairs each time a course is offered. Further information about this policy may be found at http://www.registrar.appstate.edu/admin/meetdateexempt.html.

Term ________ Year _____________

Course Subject __________ Course Number __________ Section(s) ____________

Is this course a Distance Education course? Yes No Is this course a Main Campus Summer course? Yes No Instructor ______________________________________ Requestor ______________________________________

Course Start Date: ___________________ Course End Date: ____________________

Exception to regular academic course meeting dates (check all that apply): Class ends after the regular term dates Class starts before the regular term dates

Class meets on weekend(s) Dates are necessary for student to complete internship requirements

Class meets on holiday(s)

Reasons/Justification for exception to standard academic course meeting dates:

How have you addressed class grading dates that may differ from the standard grading dates for the term?

How have you addressed issues such as Financial Aid and graduation that might affect students enrolled in a course that meets outside the standard course meeting dates?

Approvals: Department Chair ____________________________________ College Dean _________________________________ Academic Affairs ____________________________________

Completed and approved forms for Main Campus, Spring and Fall courses should be turned into to the Registrar’s Office or sent via e-mail to infoserv@appstate.edu. Summer forms can be turned into Lynette Orbovich at orbovichln@appstate.edu and Distance Education forms can be turned into Sara Speed at speedse@appstate.edu.

Office Use Only Date Received ______________________________ Date Processed ______________________________

Is this an internship? Yes NoIf Yes, please indicate the: Student Name: ______________________________ Student ID: _______________________________