Recreation Studies Fieldwork & Internship Agency Form : Department of Health & Human Performance : Texas State University

Agency Legal Name *

Facility Address *

Preferred Term of Agreement *

Terms can be 1-5 years

Affiliation Contact Information (Person signing agreement: Name Title/Position) *

Phone Number *

Email *

Preceptor Contact Information (Person supervising student: Name/Title Position) *

Phone Number *

Email *

Years at Agency (Note: If you’ve been at your agency less than a year you cannot accept an intern at this time) *

Qualifications of the Preceptor *

What is the mission/purpose of this agency? *

Have interns been here before?

Yes

No

Number of interns that will be on site during this placement term *

Anticipated intern duties and responsibilities *

Anticipated work schedule (Approximately 20hrs per week for Fieldwork; 30-40hrs per week for Internships *

Are you interested in accepting fieldwork (pre-internship), internships, or both? (check all that apply)

Fieldwork (pre-internship = 200 hours)

Internship (Internship = 400 hours)

Which semester can you take students? (check all that apply)

Spring

Summer

Fall

Do you have at least one full-time (30 hours) recreation administration professional on staff that can supervise interns? *

Yes

No

Are you interested in accepting fieldwork (pre-internship), internships, or both? (check all that apply)

Fieldwork (pre-internship = 200 hours)

Internship (Internship = 560 hours)

Which semester can you take students? (check all that apply)

Spring

Summer

Fall

Do you have at least one full-time (30 hours) CTRS on staff that can supervise interns and has held their certification for at least 1 year? *

Yes

No

Have you completed the ATRA Quality Internship Supervisor Training? *

Yes

No