1. Spring 2018 Internships

2. COMMUNITY HEALTH EDUCATION
Info packet & required forms are on my website:
then click on Internships link
EXERCISE SCIENCE
COMMUNITY HEALTH EDUCATION
120 hours required (12 hrs/week)
240 hours required
(24 hrs/week)
Terms runs from April 2nd – June 8th.
Hours cannot be started until April 2nd and forms MUST be received on April 3rd.
If forms are late, hours may NOT be counted until forms are received.

3. Forms due at next meeting.
You should have a placement…..
The site must be approved by appropriate internship coordinator.
Ada Massa Gonzalez for EXS / Janet Roberts for CHE
Complete forms B & C
See Internship Coordinator regarding form A
TYPED except for signatures
Handwritten forms will NOT be accepted.
Incomplete forms
Points will be deducted for incomplete or inaccurate information.
Forms due at next meeting.

4. Form A – Master Agreement (if applicable)
This agreement is entered into this ___ day of ___ 20__ (“Effective Date” between Western Oregon University (WOU), an Oregon non-profit cooperation and education institution (WOU), and ____ (The “Experience Provider”) located at _____.
First line example: 20th day of April 2015
_______ (The “Experience Provider”) = company name NOT person’s name
Example: PTNorthwest; Marion-Polk Food Share; etc
Located at __________ = physical address (street address, city, state, zip)
Example: 345 N. Monmouth Ave, Monmouth, OR 97361
Make sure ALL blanks are filled in
The Experience Provider = the name of the company where you will be interning.

5. Form A continued – Page 1 CHE EXS For Experience Provider: For WOU:
Name:
Janet Roberts
Ada Massa Gonzalez
Address:
345 N Monmouth Ave,
Monmouth, OR 97361
Telephone:
(503)
(503)
Note: For Experience Provider, the information will be supervisor’s name and
Information; however, signature on 2nd page needs to be the person who can
Legally sign contracts.

6. Form A – Master Agreement page 2
Experience Provider: Western Oregon University: By: (Signature) By: Internship Coordinator signs Name: Print name Name: Internship Coordinator prints name Date: Date: Note: Experience Provider’s signature here will be whoever at the organization may legally sign contracts.

7. Form B – Student Agreement
Student Name: Your name Internship Start Date: 4/2/2018 End Date: 6/8/2018 Department and Course Number: Either HE419 or EXS419 Quarter Enrolled: Spring Year: 2018 Credit Hours: 8/4 Internship Site (“Experience Provider”): Internship Company Name Complete Internship Address: Street #, Street, City, State, Zip Site Supervisor: Supervisor’s first and last name Phone: Supervisor’s phone# Supervisor’s

8. Form C - Objectives Fill out the top of the form
Do NOT hand forms to your site supervisor to fill out!
Objectives need to be TYPED and in correct format (see instructions)
“To research fall prevention programs by July 15th, ”
To assist with 3 new patient assessments by June 1st, 2017”
Personal versus Agency objectives

9. Form C continued
You will need to meet with your site supervisor before you start your internship to determine objectives.
KEEP a copy of form C for your records.

10. Upcoming Meetings Meetings are MANDATORY!!
Tuesday, April 3rd, 4pm, Location RWEC 201
We will a reminder

11. Check WOU email regularly
CHE CRN
EXS CRN
30221
30185