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Atlanta BEST ProgramTrainee Internship Application Form

Trainee information

Today"s Date*

Date

Last name*

First name*

Email*

Cohort*

Institution*

University Status*

Residency Status*

Internship Site Information

Name of Internship Partner organization*

Description of the organization*

Organization Address Street*

City*

State (Include country if not in US)*

Intern Supervisor Information

Contact Name*

Contact Phone*

Contact Email*

Location of Work

All on siteMix of onsite and all virtualAll virtual

BELOW: If the internship site is the same address as the organization address, indicate "same as above"

Internship Site Address Street*

Internship Site Address City*

Internship Site Address State (Include country if not in US)*

Internship Experience Information

Structure of Internship (48 minimum contact hours)*

Hourly based, with set duration (i.e. 6 weeks)Project based, 1-3 main projects

Start date:*

Date

End date:*

Date

How many weeks*

Number of hours per week (including travel time, if applicable)*

Compensation*

If you will be paid- what percent %of your salary will be covered by the internship partner?

Additional Info:

Which Career Track does this correspond with ( http://gs.emory.edu/sites/best/tracks.html )*

Trainee Responsibilities & M easurable Outcomes? (i.e. Bullet Points of number/type of activities you will complete, such as presentations, proposals, projects, etc*

When appropriate, the BEST Program reserves the right to set additional requirements in conjunction with this worksite program, such as additional readings, journals, written assignments, etc. It is the responsibility of the trainee to meet with a BEST program team member and intern partner to determine policies, procedures, assignments, and evaluative measures, if any.

What are your expected learning outcomes?*

How did you hear about this opportunity?*

The below signatures will be collected when each stakeholder agree to the above experience. The BEST program signature is the first to sign off. Do not start collecting signatures until BEST approves this experience.

1) BEST Program Signature:________________________ Date: ______________________

Print Name:

2) Faculty Signature:________________________ Date: ______________________

Print Name:

3) Internship Supervisor Signature:________________________ Date:___________________

Print Name:

4) BEST Trainee Signature:________________________ Date: ______________________