Internship Learning Contract
(To be completed for ALL internships taken for credit – NO retroactive applications for credit)
Career Services
1101 West College Avenue
Jacksonville, IL 62650
Phone: 217.245.3040 Fax: 217.245.3167
Student Information (please print legibly)
Student Name
____
Grade Level
ID NO _________________________ Major
Mailing Address (during internship)
Number ___________ Street _______________________ Box /Apartment
City
___________ _ State
Zip
_
Phone
E-mail
Semester of internship:
Fall
Spring
Summer
Year: ______
Illinois College Faculty Internship Supervisor Information (please print legibly)
Name
Phone _______________________________ E-mail
Site Information (please print legibly and include an email – correspondence will be sent electronically)
Organization or Company Name
Address
City
_ State
Zip
Site Supervisor Name _________________________________ Title
Phone ________________________________ E-mail
Learning Contract Agreement
The signatures of the undersigned indicate approval of this internship, as described in this learning
contract. Amendments may be made to the contract in writing and will be accepted with the
signatures below.
Student Signature:
Faculty Internship Supervisor Signature:
Site Supervisor Signature:
Career Services Signature:
Note: ALL internship contracts must be completed and returned to Career Services prior to the 10 th day of
classes for fall and spring terms. Summer internship contracts are due by June 1 st. ALL internship contracts
must be submitted by deadlines or credit will not be applied. LIMIT of 16 hours of Internship credit can be
counted towards graduation requirements.
Internship Learning Contract PAGE 2
Internship Information
Paid _____ Unpaid _____ Payment type
Start Date: ___________________ End Date: ______________________
Internship Summary
Describe the responsibilities, tasks, and/or projects to be completed during the internship by
the intern at the internship site. (Section to be completed by intern with input from site and
faculty supervisors.)
1.
2.
3.
4.
Learning Objectives
Describe knowledge and/or skills to be gained from this internship. (Section to be
completed by intern with input from site and faculty supervisors.)
1.
2.
3.
4.
Academic Requirements (Section to be completed by faculty supervisor.)
Course Number & Title: ______________
Academic credits to be earned: ______
On-site internship hours needed per credit:
Reflection/Assignment hours needed per credit:
Note: The sum of on-site
and reflection/assignment
hours should equal at least
45 hours per credit hour.
Academic Work Required for Internship Credit and Criteria for Evaluation and
Grading:
Due Date of Final Academic Work Requirements
Illinois College Office of Career Services
LIABILITY RELEASE, STUDENT OR PARTICIPANT WAIVER
ILLINOIS COLLEGE OFF-CAMPUS PROGRAMS
Program Name ______INTERNSHIP PROGRAM____________
I,___________________________ , am applying for participation in the above-listed program
(“program”) offered by Illinois College (“College”). I am not required to participate in this program,
although I may receive academic credit through participation in it. In consideration for being
permitted to participate in the program, the receipt and sufficiency of which is hereby acknowledged,
I agree and represent as follows:
1. I understand that, although the College will attempt to maintain the program as described in its
publications and brochures, it reserves the right to change the program, including the itinerary, travel
arrangements, or accommodations, at any time and for any reason, with or without notice, and that
neither the College nor its trustees, officers, employees and agents, shall be responsible or liable for
any expenses or losses that I may sustain because of these changes.
2. I further understand that the College reserves the right to establish rules for the operation of the
program, and I will comply with those rules. The College, in its sole discretion, may terminate my
participation in the program if I violate the rules or behave in a manner which is disruptive or which
could impede or obstruct the progress of the program in any way, or affect adversely the reputation
of the program or the College. If I am a student at the College, I understand that, if my participation
in the program is terminated, I will receive no academic credit nor receive a refund of any program
fees.
3. I understand that although the College has made every reasonable effort to assure my safety while
participating in the program, I hereby acknowledge my awareness that my participation in the
program may expose me to risk of property damage and bodily or personal injury, including death. I
understand that the risks I may encounter include airplane crashes, motor vehicle accidents, and
other travel-related accidents; cuts, bruises, broken bones, sickness, and other injuries and healthrelated occurrences; criminal acts; as well as other risks that may not be foreseeable. I have
investigated the risks, and I hereby assume any and all such risks, and I release and promise not to
sue the College or its trustees, officers, employees, agents, successors and assigns.
4. For the sole consideration of the College arranging for my participation in the program, I,
individually, and on behalf of my heirs, successors, assigns and personal representatives, hereby
release and forever discharge the College and its governing board, their members individually, and
their officers, agents and employees (in their official and individual capacities) from any and all
claims, demands, rights and causes of action of whatever kind, arising from or by reason of any
personal injury, property damage, or the consequences thereof, resulting from or in any way
connected with my participation in the program and/or any travel incident thereto, including any acts
of negligence on the part of the College, its trustees, officers, employees or agents.
5. I have or will secure comprehensive health and accident insurance to provide adequate coverage
for any injuries or illnesses that I may sustain or experience while participating in the program. By my
signature below, I certify that I have confirmed that my health care coverage will adequately cover
me while I participate in the program, including any travel outside the United States, and I hereby
release the College, and its employees and agents, from any responsibility or liability for expenses
incurred by me for injuries or illnesses (including death) that I may incur because of those injuries or
illnesses, including medical bills, charges, and similar expenses.
6. I authorize any representative of the College to secure dental and medical treatment for me if I am
injured or become ill while participating in the program, including without limitation anesthetic and
surgical treatment, and further authorize any representative of the College to sign authorization
forms necessary to obtain the treatment. Neither the College nor its employees and agents shall be
responsible or liable for any expenses or damages I may incur as a result of the College acting
pursuant to this grant of authority.
7. I, individually, and on behalf of my heirs, successors, assigns, and personal representatives, agree to
indemnify, defend, and hold harmless the College, and its trustees, officers, employees, agents,
successors, and assign (in their official and individual capacities), from any and all liability, loss,
damage, claim, suit, and cost which arises out of, occurs during, or is in any way connected with my
participation in the program or any travel incident thereto, including claims and suits arising out of
any of my alleged acts or omissions, and any claim or suit made on my behalf by my legal
representatives, heirs, successors, and assigns.
8. I agree that, should any provision or aspect of this agreement be found to be unenforceable, all
remaining provisions of the agreement will remain in full force and effect.
9. I represent that my agreement to the provisions herein is wholly voluntary, and further understand
that, prior to signing this agreement, I have the right to consult with the advisor, counselor, or
attorney of my choice.
10. I agree that, should there be any dispute concerning my participation in the program that would
require the adjudication of the court of law, such adjudication will occur in the courts of, and be
determined by the laws of, the state of Illinois.
11. This agreement represents my complete understanding with the College concerning the College’s
responsibility and liability for my participation in the program, supersedes any previous or
contemporaneous understandings I may have had with the College on this subject, whether written
or oral, and cannot be changed or amended in any way without my written concurrence.
12. I understand that my involvement with an internship will be shared to acknowledge internship
experiences students complete to current and prospective students, faculty, and staff. This can
include, but not be limited to, public display boards, news articles, and campus-wide dissemination.
13. I represent that I am at least eighteen years of age or, if not, that I have secured below the
signature of my parent or guardian as well as my own.
Signature of Student
Print Name
Date
Illinois College Office of Career Services
1101 West College Avenue
Jacksonville, IL 62650
Phone: 217.245.3040
Fax:
217.245.3167
Registrar -Internship Registration Form
This form registers the internship with Career Services to receive prearranged credit.
Today’s Date:
Semester:
Fall
Spring
Summer
Year: _______
Name:
Last
First
MI
Student ID #: ________________________
Faculty Internship Supervisor
Internship Course Number & Title
________________________________________ Credit Hours
Intended Internship Organization
(Name of Company / Organization)
Internship Site Address
Internship Site City, State, Zip
Student Signature
Date
Faculty Internship Supervisor Signature
Date
Career Services Signature
Date
ALL internship contracts must be completed and returned to Career Services prior to the 10th
day of classes for fall and spring terms. Summer internship contracts are due by June 1st.
ALL internship contracts must be submitted by deadlines or credit will not be applied.