Student's Name:                                      
Address:
City:                                              State and Zip Code:Phone:                          
Email:
Major:                                        Area of Concentration:

University Internship Supervisor:  David Ebitz
Address:  212 Arts Cottage, School of Visual Arts, Penn State Univ, University Park, PA 16802
Phone:     (814) 863-1004            Fax:  (814) 863-8664            
Email:  This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

Museum or Institution:
Address:
City:                                       State and Zip Code:
Museum Supervisor:
Phone:                                   Fax:
Email:

Internship Title:

Credit:

I. DURATION    A. Starting Date:                B. Closing Date:               
II. HOURS    A. Number of Weeks:            B.Days per Week:            C. Hours per Day:   

These hours are to be divided as follows (approximate percentage):

D. In the Museum:           
E. Travel or Field Work for the Museum:           
F. Assignments Outside of the Museum:             

III. OBJECTIVES OF THE INTERNSHIP
Specify the professional and career development objectives to be achieved during the internship. Include specific skills the intern will learn (such as conducting research, scheduling visits, giving gallery tours, and writing lesson plans) and more general learning objectives (such as understanding the field in which the internship is taken, and developing interpersonal skills).

IV. INTERN RESPONSIBILITIES Specify the duties and responsibilities of the intern to the museum. These should be stated clearly and concisely in order to avoid uncertainty during the course of the internship and at the time of the final evaluation.

V. UNIVERSITY SUPERVISOR RESPONSIBILITIES In consultation with the museum supervisor and intern, establish the internship assignment and schedule.  Maintain contact with the intern and museum supervisor.  Read and respond to the journal and other written assignments of the intern.  Make one site visit, if possible, to observe, meet with the intern and museum supervisor, and provide feedback.  Assign an academic grade for the internship after reviewing the final evaluation provided by the museum supervisor.

VI. MUSEUM SUPERVISOR RESPONSIBILITIES

A. Training/Education. Specify how the supervisor and museum will educate and prepare the intern in order to facilitate his or her achievement of the objectives specified under "Objectives of the Internship," Section III.                                                                   

B. Feedback. Indicate arrangements for sessions (daily, weekly, monthly) to be held between the supervisor and intern for the purpose of constructive suggestions, guidance, and on-going evaluation.                                                                                             

C. Midterm and Final Evaluations. Specify date for a midterm oral evaluation between the intern and supervisor. The results of this evaluation should be communicated to the university supervisor.  Prepare a final written evaluation of the intern, using the form provided by the university or an equivalent form used by the museum.  Copies of the final evaluation should be provided to both the intern and the university supervisor.

VII. OTHER SPECIFICATIONS:

VIII. TO BE COMPLETED BY ALL PARTIES:I agree to the conditions of the internship stated in the parts that pertain to me.

Intern's Signature                                                                                             Date

Museum Supervisor's Signature                                                                         Date 

University Supervisor's Signature                                                                      Date

cc:  Intern, Museum Supervisor, University Supervisor, Intern's student file

Rev. 5/10/05