ࡱ> LNKy bjbj D${{$$~~84N$Wr$O!"~~&&&^~~8&&&&; j&'0W&t&&:|&W$ D:  HSSP 89a Academic Internship Approval Form Health: Science, Society, and Policy (HSSP) Program The Internship Approval Form serves as a learning contract between you and the host agency. After the internship is secured, please fill this form out in consultation with your supervisor and mentor. To receive academic credit for your internship, this form must be submitted to Cynthia Tschampl ( HYPERLINK "mailto:tschampl@brandeis.edu" tschampl@brandeis.edu) and the internship approved by our program prior to beginning the internship. Student Information Name: Email: Phone: Class Year: Brandeis Mailbox/ Local address: If a summer internship: Summer Address: Summer Phone: Supervisor Information Name: Title (Dr./Mr./Ms.): Position: Phone: Email: Address: Internship Placement Internship Site: Expected Dates of Internship: Expected Hours/Week (minimum is 110hrs over 5wks in summer and 100hrs over 8wks during a semester): Paid/Unpaid: Potential Source(s) of Funding: Brief description of organization (mission, projects, size): Brief description of intern activities and responsibilities: Brief description of the relationship between this internship, and your personal goals to acquire knowledge, develop skills, and explore potential career avenues: To be filled out by the HSSP Internship Instructor: Program Requirements Met: ./cd+ g ν{rfXOAOjhOICJU\aJhOICJ\aJhwh6CJ\aJhwhCJ\aJhACJ\aJhITh5CJ\aJhDhCJ\aJhCJ\aJ!hAhA56@CJ\aJh)=5>*@CJ \aJ !hAh)=5>*@CJ \aJ hAh65>*CJ \aJ h)=5CJ\aJ h;l^hpjhpUjhpU/cd! 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