CENTRAL CONNECTICUT STATE UNIVERSITY



CENTRAL CONNECTICUT STATE UNIVERSITYDepartment of Counselor Education & Family TherapyStudent Development in Higher EducationApplication for Academic Internship – CNSL 592NAME: __________________________________________ ID. # ___________________________DAY TIME PHONE: _______________________________DATE: _________________________E-MAIL ADDRESS: ___________________________________________________________________Eligibility Requirements (due at time of first class):Academic Internship agreement with college/university with appropriate supervisor (SDHE – 6)Proof of professional liability insuranceTaskstream accountNOTE: The forms are available in the spinner outside of the office (Carroll Hall) or online at the Program Web page. Deadlines:March 15Fall and Spring Academic InternshipI wish to apply for admission into CNSL 592: Internship in Student Development in Higher Education, for the following semesters:Semester: FORMCHECKBOX Fall & Spring Academic Year____________514353365500Advisor ApprovalI have reviewed the student’s file, including the C3 survey and transcripts, and certify that the student is ready to enter CNSL 592: Internship in Student Development in Higher Education. _______________________________________________________Signature of AdvisorDate Potential Academic Internship Sites: ................
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