ENROLLMENT FORM

School Psychology Paid Internships for Out of State Graduate Students

Directions: Complete the following information to enroll the LEA and out of state graduate student into the "School Psychology Paid Internship" program. Once the form is submitted, a statement of agreement will be sent to the LEA's school psychologist site supervisor.

I. Local Education Agency Information

Name of Local Education Agency *

Street Address *

Address Line 2

City *

Zip Code *

Type of LEA *

Intermediate Unit in which the LEA is a member district *

Upload the LEA's W-9 *

II. Grant Contact Information

Name of School Psychologist Site Supervisor *

Work Email Address *

Work Phone *

III. Out of State School Psychology Graduate Student Information

Name of School Psychology Intern *

School Psychology University Program Student Is Enrolled In *

Student Email Address *

Graduate Student State of Primary Residency *

Upload verification of student residency * 🛈

Notes for APR Core Team