PLTS Internship Arrival Form (Word and Sacrament)

First Name

Last Name

Pronouns

Home Address (while on internship)

Country

Street

City

Region

Postal Code

Cell Phone Number

Period of Internship

Start Date

End Date

Type of Internship

Single Site

Two Site

Ministry Site Information

Ministry Site Name

Country

Street

City

Region

Postal Code

Phone Number

Website

Social Media

Supervisor Contact Information

Name

Pronouns

Phone

cell

office

Supervision Meetings

Day

Time

Frequency (weekly, every other week, etc.)

Lay Committee Chair or Contact Person

Name

Pronouns

Phone

cell

office

home

Lay Committee Meeting Schedule

Congregational Financial Commitment

Monthly Stipend

Business Mileage Reimbursement/mile

If congregation assists with FICA payments, to what degree? (dollar amount):

Monthly amount for 'other' reimbursable expenses

Other Financials
select all that apply

Housing and utilities reimbursed

Housing and utilities paid directly to landlord

Housing owned and utilities paid by ministry

Housing not provided (must be previously agreed upon with approval by the Director of Contextual Education)

Internship Administrative Fee ($2,000.00)

Comments on above as needed

2nd Site Information

Site Name

Country

Street

City

Region

Postal Code

Phone Number

Website

Social Media

Supervision Meetings (2nd Site)

Time

Day

Frequency (weekly, every other week, etc.)

2nd Site Financial Commitment

Monthly Stipend

Business Mileage Reimbursement/mile

If site assists with FICA payments, to what degree? (dollar amount):

Monthly amount for 'other' reimbursable expenses

Comments on above as needed