INTERNSHIP PERMISSION FORM

WALTER PANAS WISE PROGRAM

Student’s Name: ______________________________________________________

Internship Site: ______________________________________________________

Site Supervisor: ______________________________________________________

Site Address: ______________________________________________________

Site Telephone #: ______________________________________________________

The above named student will be participating in the WISE internship program for a duration of 20 weeks for the purpose of enhancing his/her educational experience.

STARTING DATE: ___________________________________________________

COMPLETION DATE: ___________________________________________________

SIGNATURES

Student:______________________________________________ Date:_____________

Mentor:______________________________________________ Date:_____________

Program Coordinator:___________________________________ Date:_____________

Parent/Guardian:_______________________________________ Date:_____________

Guidance Counselor:____________________________________ Date:_____________

Internship Site Supervisor:_______________________________ Date:_____________

PARENT/GUARDIAN EMERGENCY NUMBER:______________________________