LINDENWOOD UNIVERSITY

SCHOOL OF EDUCATION
INTERNSHIP PLACEMENT FORM

Name: _________________________________________________________
Email: _________________________________________________________
Cell Phone: _____________________________________________________
School District/Employer: __________________________________________
Work Phone: _____________________________________________________
Lindenwood email: ________________________________________________
Position: _________________________________________________________
Conference/Plan Period: _____________________________________________
Start/End School Time: ______________________________________________
School Name: _____________________________________________________
School Address: Street ______________________________________________
City_________________________ State_____ Zip__________
Supervising Administrator: ___________________________________________
Phone: ____________________________________________________________
*Taken and Passed SLLA Assessment: YES
NO
*This information will help Lindenwood in placing you with a mentor to help with the competition of the new
certification requirements.

Stipulations:

Approval: ______________________________________

Date: ________________
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Administrative Internship Activities

Please record your hours as you complete your activities. Obtain the signature of your supervising
administrator as you complete each date and time.
Internship Time Requirement
EDA 50000
EDA 51000/51200/60800/60900
EDA 51500/61600
EDA 52000/61800
EDA 55300/65000
Total

15 hrs.
45 hrs.
45 hrs.
45 hrs.
150 hrs.
300 hrs.

Internship Activity Verification Log

Name: ________________________

School: ____________________________

Host Supervisor(s): ___________________________________________

Lindenwood Course # _____________ Title: _____________________________________
Task 1

Date

Duration
of Time

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Activity

Supervisor
Signature

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Date

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Activity

Supervisor
Signature

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