Application Form

Michigan State
University

Internship Application Form

Applying for:

Internship

Cohort:

General:

Semester: Year:
Anticipated Graduation Date:
Credits Requested:

Name:
E-Mail address:
Date of Birth: Student ID #:

U.S. Citizen: Yes No

Mailing Address (To receive mail):

Number/Street: Apt:
City: State: Zip:
Phone: ( )
Fax: ( )

FOR ADVISOR USE ONLY:	Initials	Date:
Total No. of credits (3 or 6)
Total credits completed to date	CJ GPA	Cumulative GPA

I understand that CJ 894 is a graded on a "Pass/No Credit" basis. Receiving a "No Credit" grade in the internship could result from one or more of the following circumstances:
- termination of the internship by the agency supervisor
- violation of professional ethics
- failure to meet academic requirements and deadlines
I understand that if I terminate placement after processing has begun, further applications may not be accepted.
I give permission for the above information to be released to approved criminal justice internship agencies.

I accept.

I do not accept.

Internship and Cooperative Education Insurance and Liability Form

No Criminal Justice Internship agency assumes liability for injury the student might sustain while participating in the internship/cooperative education program.
Unless you are already covered by a health insurance policy, you will be expected to sign up the student health insurance policy offered through MSU.
It is the responsibility of the individual student to work out the details and requirements for the student health insurance policy. Contact Olin Health Center at 517-355-4510. For assistance, contact the Chickering Group at 1-800-859-8452 or MSU Benefits at 517-353-4434 ext. 536.

I certify that I have read the information above and that I have subscribed to the MSU student health insurance policy or possess coverage of another insurance policy offering equal coverage. I waive the right to submit a claim to Michigan State University or any criminal justice internship agency as a result of injuries or illness sustained while participating in the Criminal Justice Internship Program.

Students who furnish false information on this form will be subject to disciplinary action, including possible dismissal from the Criminal Justice Internship/Cooperative Education Program.

Name of Insurance Company:
Policy Number:

I accept.

I do not accept.

This form will be sent to the internship coordinator.

CJ MA Page | School of Criminal Justice | VU Preview Page | CJ 894