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California Lutheran University
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PLTS Internship Arrival Form (Word and Sacrament)
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First Name
Last Name
Pronouns
Home Address
(while on internship)
Country
Street
City
Region
Postal Code
Cell Phone Number
Period of Internship
Start Date
Start Date
January
February
March
April
May
June
July
August
September
October
November
December
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2023
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2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
End Date
End Date
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
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5
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31
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Type of Internship
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
Email
Phone
cell
office
Supervision Meetings
Day
Time
Frequency (weekly, every other week, etc.)
Lay Committee Chair or Contact Person
Name
Pronouns
Email
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
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
Submit