Internship Proposal/Application Step 1 of 2 50% Name(Required) First Last Email(Required) Enter Email Confirm Email Student ID #(Required) PhoneA 294-level internship indicates you have already completed a 293-level internship in the same field of study. E.g., after completing BIO 293 Internship in Biology you would then take BIO 294 Internship in Biology. Refer to the Internship Overview document for more information. Course Number(Required)293 - Internship I294 - Internship IISubject(Required)Please ChooseACCAGRAHSANTARTASLBIOBUSCHECISCMNCRJCSCECOEDUEGREGTEMSENGEVSFREFSTGEOGWSHISHSVHUDHUMLATMACMATMOMMUSNUROLPPCSPHIPHYPOLPSYREESCISOCSPATHECredits(Required)Please Choose123456Term(Required)Please ChooseFallSpringSummer ISummer IIFull Summer (I & II)Year(Required)Please Choose20242025Faculty Mentor(Required) First Last Faculty Mentor Email(Required)Make sure to get this part right! Your mentor will be sent a copy of your application to approve; if their address is not accurate, they won't get the email! Enter Email Confirm Email Internship Site(Required)Name of company/organization & location Site Supervisor(Required) First Last Site Supervisor Email(Required)Make sure to get this part right! Your site contact will be sent a copy of your proposal to approve; if their address is not accurate, they won't get the email! Enter Email Confirm Email Site Contact Phone(Required)Complete the next section in consultation with your Faculty Mentor. Field of Focus or Area of Study(Required)Mentor Meetings(Required)How often and for what purpose will you meet with or contact your Faculty Mentor?Length of Internship(Required) Approximately how many weeks will the internship last?Weekly Hours(Required) Approximately how many hours per week will you be working? List min/max hours per week as well.Start Date(Required) MM slash DD slash YYYY The start date of your internship can not be before the first day of classes for the termEnd Date(Required) MM slash DD slash YYYY The end date of your internship can not be after the last day of classes for the term—however please indicate the actual end date if you will complete your internships prior to the end of the term Learning PlanWhat do you hope to gain from this internship?(Required)List specific learning objectivesWhat will your internship site gain?(Required)How will the organization or company benefit from your placement?How will you demonstrate success in achieving these learning objectives?(Required)Examples could include a daily journal of your experiences, research papers, a portfolio of creations, etc.Acknowledgement & Attestation(Required)By submitting this application you attest that you have read and/or helped to draft the learning plan and agree to fulfill and demonstrate success in fulfilling the objectives. I recognize that, as an intern from Greenfield Community College, I represent the college to the community. I therefore agree to conduct myself professionally on the job. I will meet the expectations of behavior, dress, punctuality, and industriousness commensurate with the responsibilities that I have been given. I will treat my placement workers and supervisors and the company’s/organization’s customers/clients with utmost respect. Criminal Offender Record Information Checks Students interested in participating in an academic internship that involves working with children, the disabled, or the elderly, or includes a clinical affiliation with a private or public health care provider, will be required to undergo a Criminal Offender Record Information (CORI) check. Depending on the contents of a student’s CORI report, participation in an internship, may be denied. I understand that my internship site may require a CORI check and I agree to provide the necessary documentation if requested. I also underdtand that a CORI check may be done directly by the host site company or organization. CORI checks may be performed pursuant to Mass. General Laws, Chapter 6, Sections 167- 178B, and consistent with guidelines of the Executive Office for Health and Human Services, and/or the Commonwealth’s Department of Public Health. For more information, please contact Laura Earl, CORI Officer, at (413) 775-1816. Medical Records/Immunizations Students interested in interning in health care settings, including medical offices, may be required to provide additional health information and immunization records, as determined by the facility, to be eligible. The College does not monitor or maintain records for students participating in internships, though you may be able to obtain proof of immunization and other test results from Health Records (N348) if you provided them to the College. Title IX/Affirmative Action Internship students must read and understand the College's Title IX and Affirmative Action policies. I understand I may be subject to and will comply with CORI requirements I understand I may be required to and will submit additional health and immunization information I have read and understand GCC's Title IX/Affirmative Action policies I attest that the information in this application is correct HiddenInternship Coordinator HiddenVP Academic Affairs HiddenGrouping Admin 1 HiddenGrouping Admin 2 HiddenGrouping Admin 3