WASSERMAN CENTER

INTERNSHIP GRANT
SUPERVISOR AUTHORIZATION FORM
INTERNSHIP INFORMATION (PLEASE HAVE SUPERVISOR COMPLETE)
Organization: ________________________________________________________
Address (include city, state, and zip): __________________________________________________
Supervisors name: ___________________________ Title: __________________________
Email: _______________________________ Phone: ________________________

____________________ has been hired as an intern and will complete an internship with our
student name

organization from __________ to __________ , working __________ hours per week.

start date end date

Compensation (if applicable) ________________

Total amount
*Compensation includes any funding i.e. stipends, metrocard, meals etc. If receiving non-monetary compensation please
approximate total value for duration of internship

Please describe the students responsibilities and what you expect him/her to gain from this internship.

Would you recommend this student for the grant? If so, why?

STUDENTS OVERALL PERFORMANCE

Outstanding Very Good Average Marginal Unsatisfactory N/A

SUPERVISOR: Please check this box to verify all information on this form is accurate.