FAX COVER SHEET To: Nova Southeastern University Fischler ... - 1

FAX COVER SHEET
To:
Nova Southeastern University
Fischler School of Education and Human Services
Director of Educational Leadership Internship Program
1750 NE 167 th Street
North Miami Beach, FL 33162
Fax: (954) 262-3906
Phone: (800) 986-3223, ext. 8519 or (954) 262-8519
From: Date: _______
Contact Phone: Day ( ) Evening ( ) _________
Return Fax Number: ( ) NSU ID#
NSU email account:
__________________________________
Alternate email account: ______________________________________________________________________
Total Pages (including cover sheet):

Nova Southeastern University
Fischler School of Education and Human Services
ATTN: Educational Leadership Internship Program
1750 NE 167 th Street
North Miami Beach, FL 33162
Fax #: (954) 262-3906
FORM A
EDUCATIONAL LEADERSHIP INTERNSHIP PROGRAM
Application Deadline: The Form A application must be submitted a minimum of six (6) weeks before registration
opens.
NSU Site
Date Submitted
Name (Ms. /Mr.)
NSU ID#
Address
Home Phone
Street City State Zip
Work Phone
NSU e-mail Address
Current Position ________ Internship Site
Internship Site Address
Local Sponsor’s Name
Street City State Zip
EL 698
Start Date Fall I Fall II Winter I Winter II Summer I Summer II 200__
(Circle one)
EL 699
Start Date Fall I Winter I Summer I 200__
(Circle one)
Check Degree Program:
Check Current Specialization:
…. Master’s of Science
Educational Leadership
…. Educational Specialist
Management and Administration of
…. Modified Core
Educational Programs
Students must choose appropriate Internship based on their individualized program outline created by their
Enrollment Services Representative/Academic Advisor.
.. EL 698 – 3 credits EL 699 – 6 credits