HMSV Internship Agreement Form

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

Internship semester Fall 2025 Spring 2026 Summer 2026 Fall 2026 Spring 2027
Internship Information
Agency/ Site *
Does Agency have current Memorandum of Understanding (MOU) in place with ODU?

Does Agency have current Memorandum of Understanding (MOU) in place with ODU? Yes No Unsure
To facilitate the MOU with your site:

If your site does not have a current MOU in place with ODU, then access the template here: https://www.odu.edu/sites/default/files/2025/documents/hmsv-mou.pdf

If your site can sign it as-is, submit the signed one here: https://forms.odu.edu/view.php?id=1819596

If changes are needed before your site can sign it, email the agency contact’s name and email address, and the name of site/agency so they can be connected with ODU’s legal office.

These can take weeks to move through the process, so don't delay!
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- ENTIRE FORM IN 1 PDF! *

Attach Files

HMSV Internship Agreement Form

Internship Information

To facilitate the MOU with your site:

Supervisor licensure information

Supervisor educational/academic information

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