HMSV Internship Agreement Form

Name of HMSV intern Name of HMSV intern * First Last
ODU Email *
Internship semester *

Internship semester Summer 2025 Fall 2025 Spring 2026 Summer 2026 Fall 2026 Spring 2027
Site location *

Site location Main Campus Distance Learning- Online
Internship Information
Agency/ Site *
Does Agency have current Memorandum of Understanding (MOU) in place with ODU?

If not, facilitate the process by connecting the appropriate site contact with the Internship Coordinator and provide MOU template (on CHS Website)
• If the site agrees with the terms as-is, the designated contact may sign the MOU and return it to the Internship Coordinator.
• If the site requires revisions or has questions, they should email the Internship Coordinator with contact information for the appropriate person at the agency who handles contracts or legal agreements.
Please note: The MOU process can take 6–8 weeks, so it’s essential to begin early.

Does Agency have current Memorandum of Understanding (MOU) in place with ODU?

If not, facilitate the process by connecting the appropriate site contact with the Internship Coordinator and provide MOU template (on CHS Website)
• If the site agrees with the terms as-is, the designated contact may sign the MOU and return it to the Internship Coordinator.
• If the site requires revisions or has questions, they should email the Internship Coordinator with contact information for the appropriate person at the agency who handles contracts or legal agreements.
Please note: The MOU process can take 6–8 weeks, so it’s essential to begin early. Yes No Unsure
Department/ Program of Internship
Supervisor Name Supervisor Name * First Last
Supervisor job title *
Supervisor Phone Supervisor Phone * - ### - ### ####
Supervisor Email *
Agency/ Site Address Agency/ Site Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Supervisor licensure information

(if applicable)
Type of license
State & department issuing license
License number
Expiration date
Supervisor educational/academic information

*If the highest degree earned is a bachelor's level degree, then a current copy of the supervisor's resume must be submitted with this form. Remember that supervisors must have at least 5 years of experience in the field if the highest degree earned is bachelor's level.
Highest degree earned *
Major/ program of study *
Number of years experience in HMSV field (if bachelor's level degree)
Upload Internship Agreement Form (Must upload entire form as one document!)

To upload as a PDF- you may scan using Notes app or something similar to snap pics of each page from your phone, then send the pdf to yourself. You may then download and attach that here.
Upload a File: Supervisor's resume (only needed to show 5+ years experience if supervisor has a bachelor's degree)

Attach Files
Upload a File: Internship Agreement Form *

Attach Files
I have completed the modules in the Internship Organization in Canvas *

I have completed the modules in the Internship Organization in Canvas Yes

HMSV Internship Agreement Form

Internship Information

Supervisor licensure information

Supervisor educational/academic information

Upload Internship Agreement Form (Must upload entire form as one document!)