Intern Data Form

Type of Internship:	KTIP-TPA     IECE       CTE/Vocational
2nd Semester Intern: (Intern has completed the first half of Internship)	Yes   No
Intern's Name:
Email:
Intern Assignment Grade/Subject:
Assigned Resource Teacher:
Principal:
School:
School #:
School Address:
School Phone Number:
District:
District #:
Verification:	To prevent spam, please enter the numbers you see in the image below:

Kentucky Teacher Internship Program
Western Kentucky University
ktip@wku.edu
Phone 270.745.5991 or Fax 270.745.6279