eLEARNING DESIGN SPECIALIST INTERNSHIP APPLICATION It is the student’s responsibility to submit the following forms and documents in one complete pack...
eLEARNING DESIGN SPECIALIST INTERNSHIP APPLICATION It is the student’s responsibility to submit the following forms and documents in one complete packet to Rio Salado College, Educator Preparation Office, 2323 W. 14th Street, Tempe, Arizona 85281. All materials must be submitted as noted below. Any application packet that is incomplete will be returned and it will be the student’s responsibility that all application materials listed on this check sheet are submitted. Please type or CLEARLY print entire application.
Name (Last, First, Middle)
Former Last Name(s)
Address: (Number, Street, Apartment)
(City, State, Zip)
Telephone (include area code) Home: Cell: Student Identification Number:
E-mail
1. Circle below which option you applying for: ELN290AA – eLearning Design Internship (1 credit) ELN290AB – eLearning Design Internship (2 credit) ELN290AC – eLearning Design Internship (3 credit) 2. Biographical Information Sheet: Submit completed form. _______3. FERPA: Submit signed original. _______4. Participant Acknowledgement Form Submit signed original. _______5. Clear and enlarged copy of your IVP fingerprint clearance card only if completing the internship in a preK-12 environment (front and back copy of card required). _______6. Have you been convicted of, admitted committing, or are you awaiting trial for a felony? _______7. Resume – Attach a current copy of your resume. _______8. Date available to start eLearning Design Specialist Internship: Please note: 80 hours to be completed over a 15-week period. □ Fall 20________ eLearning Design Specialist 2016-2017
□ Spring 20________
□ Summer 20________
Yes
No
_______9. Name of business/organization where you are requesting placement for the Internship: Must provide up to three business/organization choices: Name of business/organization: Address: HR Director/Coordinator Name: HR Director/Coordinator Information(email/phone):
Name of business/organization: Address: HR Director/Coordinator Name: HR Director/Coordinator Information(email/phone):
Name of business/organization: Address: HR Director/Coordinator Name: HR Director/Coordinator Information(email/phone):
I verify that the application information I have submitted in this packet accurately represents my prerequisite coursework as required by the Rio Salado College eLearning Design Specialist program. Once accepted, the student understands that current tuition rates for 1-3 credit hours and a $15.00 registration fee will be assessed. ______________________________________
____________
SIGNATURE
DATE
eLearning Design Specialist 2016-2017
BIOGRAPHICAL INFORMATION
Name: Please let us know what led you to pursue the eLearning Design Specialist certificate. Be as thorough as possible without being too expansive. Please sign and date your biographical information.
Signature: __________________________________
eLearning Design Specialist 2016-2017
Date: _______________________
FERPA eLEARNING DESIGN SPECIALIST INTERNSHIP Release of Information Form Main Campus: 2323 W. 14th Street, Tempe AZ 85281 | Phone: (480) 517-8126 | Toll Free (800) 729-1197 | Fax (480) 377-4713
STUDENT NAME: __________________________________________________________ The eLearning Design Internship is a partnership between Rio Salado College, and participating business/organization. In order to ensure success of your internship, it is imperative that we share information about your coursework/progress with all partners. By completing this form you are granting permission for our office to discuss your status with other designees. I authorize Rio Salado College to share with any business/organization information associated with my education record (ie. Completion of coursework) that will assist with completion of the eLearning Design Specialist Internship. ________________________________________________________
__________________
Signature of Student
Date
Return form to: Educator Preparation: Field Experience Office 2323 W. 14th Street Tempe, AZ 85281 FAX: (480) 377-4713
eLearning Design Specialist 2016-2017
eLearning Design Specialist Internship Participant Acknowledgement Form Student Name: Student ID #: As a participant in the Rio Salado College eLearning Design Specialist Program, I understand eligibility for internship placement and continued participation is dependent on the following:
80 hours of eLearning design work experience in industry or education per credit hour. 80 hours per credit hour must be completed within the duration of the course (15 weeks). Placement requires the Site Supervisor have a background in Instructional Design or Educational Technology. If I withdraw myself from my internship placement that I may receive a non-passing grade, may not be offered another opportunity to complete the internship. I will incur a $200.00 rescheduling fee per incident if I: 1) Cancel a confirmed placement 2) Refuse to accept a confirmed placement. Payment for my eLearning Design Specialist Internship course(s) is due 10 days prior to the course start date. Once I receive an email notification of charges from Rio Salado College, I will call Rio Cashier’s at (480) 517-8334 and take responsibility for the balance on my student account or I will be dropped from my course. If applying for Financial Aid, it is my responsibility to verify with the Financial Aid office my eligibility of coverage for my internship course. I must regularly check my Maricopa email account for critical emails from the Field Experience Coordinator(s). If my contact information changes, it is my responsibility to update my contact information at my.maricopa.edu.
