Center for Leadership & Learning
School Counseling & Leadership
Crabaugh Hall,
1-479-498-6022 ~ 1-479-498-6075
2004 - 2005
School Counseling & Leadership
AGREEMENT OF JOINT RESPONSIBILITY
This
agreement of joint responsibilities is made between
II.
Objectives
and Purpose
One
of the objectives of this program is to prepare people to work as school
counselors in the public schools.
It
is the purpose of Tech to partner with the Internship Site for the student
presently enrolled in the School Counseling & Leadership program to provide
he/she with experiences for educational/learning opportunities through a school
counseling internship.
III. Responsibilities
Both parties mutually agree to the following joint
responsibilities:
A. Interns must document adherence to the National
Standards for School Counselors from the American School Counselor Association
(ASCA) and the State Standards for School Counselors from the State of
B. The Internship Site and Tech will cooperate in the agreement of joint responsibilities of interns, each sharing responsibility for the intern’s experience and supervision.
C. It is the understanding of all parties that the information shared during the internship must be held confidential.
D. Either party may terminate this agreement by giving the other written notice of termination. The agreement may be terminated at any time by mutual consent.
E. The intern will consult with the site supervisor and
course instructor to formulate a personal learning contract that will document
specific learning goals, learning objectives, and evidences of performance.
IV. Signatures
_______________________________________ _______________
____________________________________________ _________________
Internship
Site Supervisor (Counselor) Date
_______________________________________ ________________
Superintendent (or Designee) Date
_______________________________________ ________________
Internship Site Manager (Principal) Date
_______________________________________ ________________
School
Counseling Course Instructor Date
_______________________________________ ________________
Director,
Center for Leadership & Learning Date
I understand that as an intern I represent, not
only myself, but
_______________________________________________ ___________________
Counseling Intern
Date
School Counseling & Leadership
INTERNSHIP PLACEMENT APPLICATION
I. Identifying Information
Name:____________________________________ Date:_____________
Address:____________________________
Town/Zip:_______________
Phone:__________________Cell:_____________FAX:_______________
Semester Internship Request:___________________
Semester Year
II. Site Information
Please
complete the following information concerning your selected Internship Site:
Name of Site:
______________________________________________
Site Address:
______________________________________________
Site Phone: ______________________ FAX: ____________________
Name of Superintendent:
___________________FAX:______________
Phone:
___________________
Name of Principal On-Site:
____________________________________
III. Profile information of the person who will supervise you
at the Site
Name:
____________________________________________________
Position:
___________________________________________________
Official Work
Location:_________________________________________
Phone: _________________________FAX: __________________
Graduate
Degree(s) and/or Professional Specialization: ______________
___________________________________________________________
___________________________________________________________
Certificate/License:
___________________________________________
___________________________________________________________
___________________________________________________________
Years of school counseling
experience: ___________________________
Other professional experience: __________________________________
IV. Program of Study
Internship
Schedule
Please indicate the appropriate course for your
internship:
_______ COUN
6302 _______
COUN 6304
V. Signatures
This
Internship Placement form serves to document that the school
counseling
intern has consulted the persons below regarding placement.
Each
signature indicates concurrence with the placement of the intern.
____________________________________________ _________________
Student
Counseling Intern* Date
_______________________________________ ________________
Internship Site Supervisor (Counselor) Date
_______________________________________ ________________
Internship Site Manager (Principal) Date
_______________________________________ ________________
School Counseling Course Instructor Date
_______________________________________ ________________
Director,
Center for Leadership & Learning Date
*The student intern will provide a completed copy to each person who has signed the above form no later than the end of the first week of the placement.
School Counseling & Leadership
INTERNSHIP LOG
Intern’s
Name: ___________________________________Student I.D. Number:
_______________________________
Internship/Placement
Site: _________________________________Site Address:
______________________________
Site Manager
(Principal):__________________________Site Supervisor (Counselor):
___________________________
Manager’s
Phone & FAX: _______________________________ Supervisor’s Phone & FAX:
______________________
The Intern is responsible for
maintaining this log. Your supervisor and course instructor will review the log
monthly. Use the Cumulative Hours form below to summarize the time you
spent in each activity. Document each of the actual activities in the
Internship Log.
Cumulative Hours
HOURS GRAND TOTAL: For the Period _________________________ to _________________________
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SITE |
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Individual Supervision |
Group Supervision |
Direct Service |
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Reporting Periods: _____ October/February _____ November/March _____ December/May
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