This request is only for non-clinical placement of students in internships. For clinical agreements, please contact your department for proper procedure.
Internship Coordinator/Instructor/Dept. making request:
Please select the session and year that the Affiliation Agreement is required for placement.
Use Ctrl or Shift keys to multi-select.
On-Site Supervisor/Contact Person
Please click on "save and continue" to submit this form. If you have any difficulty completing this form contact firstname.lastname@example.org