ContractInternship Placement Contract • February 7th, 2019
FORM #2 UVM Graduate Counseling Program INTERNSHIP PLACEMENT CONTRACT The following constitutes an agreement among the intern, site-supervisor, and UVM faculty supervisor. This agreement specifies each person's responsibilities in fulfilling the Counseling Program on-site requirements of the internship. This form is to be completed by the site-supervisor and intern, and submitted to the UVM supervisor with a copy of the site-supervisor's credentials/resume. Original is kept inthe student's permanent file. Submit by May 1st prior to start of internship. PLEASE PRINT CLEARLY Student Name: Student Home and/or Cell Phone: Placement Agency/School Name: Agency/School Phone: (If school, indicate elementary, middle or high school level.) Please check one. ELEMENTARY MIDDLE HIGH SCHOOL Placement/Agency Mailing Address: Name of Agency Administrator/School Principal: Site-supervisor Name: Site-supervisor’s licensure/certification Type and Number. (Resume*) Site-supervisor
INTERNSHIP PLACEMENT CONTRACTInternship Placement Contract • April 13th, 2015
WRITTEN RECORD: The Internship student will maintain a detailed written record of activities in which he or she is involved including supervisory hours, observations, appointments with clients, meetings, submit a weekly summary grid, and end-of-semester summary grids.
