EmailMe Form - Internship Enrollment Status Form

Name *

First Last

LHU Student ID Number *

Email *

Phone *

### - ### - ####

Degree Seeking *

Major *

Internship Location *

Internship Hours *

Length of Internship (weeks) *

Internship Start Date *

MM / DD / YYYY

Internship End Date *

MM / DD / YYYY

LHU Internship Advisor Name *

First Last

LHU Internship Advisor Email *

Electronic Signature *

By typing your name in the Electronic Signature box above, you are confirming you are the student listed above. You authorize Lock Haven University to award your financial aid.

Date Signed *

MM / DD / YYYY