University of Wisconsin – La Crosse
Department of Exercise and Sport Science

ESS 789 – HUMAN PERFORMANCE INTERNSHIP CONTRACT

Internship Information	
Semester:	 Fall	 Spring	 Summer	Year:	     	
Dates (Specific):	     	to	     	
Rate of Pay (if any):	     	
Other Benefits (if any):	     	
Typical Hours:	Monday:	     	to	     		Tuesday:	     	to	     	
	Wednesday:	     	to	     		Thursday:	     	to	     	
	Friday:	     	to	     		Saturday:	     	to	     	
	Sunday:	     	to	     			     		     	

Student Information	
Name:	     	
Address (La Crosse or Permanent):	     	
Address (While Interning):	     	
Phone (La Crosse or Permanent):	     	
Phone (While Interning):	     	
E-mail Address:	     	

Internship Site Information	
Supervisor’s Name and Title:	     	
Site Name:	     	
Address:	     	
Phone:	     	Fax:	     	
E-mail/Web:	     	
Brief Description of Intern Duties:	     	

Agreement	
We certify that the above information is complete and correct. We further agree on the internship arrangement that has been established between the student and site listed above. Both the employer and the student intern have agreed upon beginning and end dates and a work schedule. Please sign below to verify agreement.

Student	Date		On-Site Supervisor	Date	

Program Director, UWL	Date		ESS Department Chair	Date	

PLEASE RETURN BY MAIL OR FAX TO:
Glenn Wright, Ph.D.
Human Performance Program Director
142 Mitchell Hall
University of Wisconsin – La Crosse
La Crosse, WI 54601
Fax: (608) 785-8172