ELO Application

Experiential Learning Application

Student's name*

First Name

Last Name

Student's Rush email*

Student's ID number*

Must include leading zeros

Rush graduate program*

Rush mentor's name*

First Name

Initial (optional)

Last Name

Rush mentor's title*

Rush mentor's phone number*

Have you discussed your Individual Development Plan with your research mentor and dissertation committee?*

Please discuss your IDP with the Graduate College Director of Career Development (per ELO work flow), and then return to this form to proceed with the submission.

Have you discussed your Individual Development Plan with the Graduate College Director of Career Development?*

Please discuss your IDP with your research mentor and dissertation committee (per ELO work flow), and then return to this form to proceed with the submission.

Are you an international student on temporary visa?*

Is the ELO at Rush or outside Rush?*

Please confirm that you have consulted with the Office of International Affairs on if and how you can obtain a Curricular Practical Training (CPT)*

Please consult with the Office of International Affairs on if and how you can obtain a Curricular Practical Training (CPT), and then return to this form to proceed with the submission.

Please report on steps you need to take to be able to obtain a CPT for this internship*

Details of the Experiential Learning Opportunity (ELO)

You must answer any of below questions, if applicable:

ELO start date*

ELO end date*

Name of ELO Organization/Company/Institution/Conference/Course/Bootcamp:*

Address of ELO Organization/Company/Institution/Conference/Course/Bootcamp:

Address Line 1

Address Line 2

City

State

ZIP Code

Where the student will work if different than the above address:

Address Line 1

Address Line 2

City

State

ZIP Code

Organization/Company/Institution/Conference/Course/Bootcamp website

Name of ELO mentor

Phone number of ELO mentor

Email address of ELO mentor

How many hours in total is this ELO?*

Reminder: ELO engagement should not exceed a total of 160 hours per academic calendar year.

What ratio of this ELO will be virtual/online?*

Is this a paid ELO?*

How much are you expecting to get paid for this ELO?*

Please proceed with submitting the form. Following up with your submission, the Graduate College might inquire for more information and documents.

If the ELO site is outside Rush, will you be receiving health insurance benefit?*

Please proceed with submitting the form. Following up with your submission, the Graduate College might inquire for more information and documents.

Do you intend to take a Leave of Absence from the Graduate College to participate in this ELO?*

Leave of Absence (LOA) requires additional paperwork. Please proceed with submitting the form. Following up with your submission, the Graduate College will inquire for more information and documents.

Describe this ELO and what you expect to learn from this experience*

Use the below template to draft a letter of intent for your ELO, collect your mentor's signature, and upload your signed letter in the next question on this form.

Garth A. Fowler, PhD
Rush University Graduate College

[Month Day, Year]

Dear Dr. Fowler,

Dr. _____________ (Mentor), my thesis committee (Drs. A, B, C, and D), and I (________________; Mentee) have agreed that my experiential learning opportunity will be comprised of ________________(LIST ELO HERE) for [INSERT TIME (start and end dates) HERE]. We believe that this opportunity will augment my graduate school experience by providing training in _____________ (TOPIC), a subject that is currently not addressed in the Graduate College curriculum. My advisory committee and mentor have agreed that this ELO is an integral part of my education. I (WILL/WILL NOT) not be compensated for participation in this experience. I (WILL/WILL NOT) take a Leave of Absence from Graduate College during this ELO. I acknowledge that my ELO engagement should not exceed a total of 160 hours per academic calendar year. I am also aware that I am required to submit an evaluation of this ELO experience by my advisory committee after successfully concluding it. Thank you for your consideration.

Sincerely,

_________________ Mentee printed name	_________________ Mentee Signature	_________________ Date
_________________ Mentor printed name on behalf of Advisory Committee	_________________ Mentor Signature	_________________ Date
_________________ IBS Program Director's name	_________________ IBS Program Director's Signature	_________________ Date

Upload your letter of intent for the ELO here.*

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Additional information you wish to provide:

By submitting this form, I contest that

all of the information on this form is correct; and,
all mentioned assignments and outcomes are discussed and agreed upon with the ELO mentor mentioned on this form.

Today's date*

Student's signature*

[clear]

Use your mouse or finger to draw your signature above