Off-campus Engagement Request Form

Off-campus Engagement Request Form

Complete this form to request permission for regular essential off-campus engagement. Please submit a SEPARATE form for each request.
Name *

First Name Last Name
Wheaton Email *
example@my.wheaton.edu
Student ID # *
Spring semester housing address (off-campus street address and unit # OR on-campus building, room/apt #) *
Are you a varsity athlete? *

Yes, fall sports Yes, winter sports Yes, spring sports No
Are you a music student at Wheaton College? *

Yes No
Academic Major *
Anticipated graduation month/year *
Name of off-campus work or internship *
City where off-campus site is located *
Name of your off-site supervisor *
If approved, your supervisor may be asked to verify they are abiding by current public health safety guidelines.
Supervisor's contact phone number *

Area Code Phone Number
Type of off-campus site (if "other" enter description) *

Work Student teaching site Internship
Are you doing this internship for credit?

Yes No
Reason for request *

Academic requirement for graduation Financial need
Please describe your duties for your internship/work? *
What is your intended work/internship schedule? *
What specific measures will be taken to keep you COVID-Safe? (i.e., will you be wearing masks, social distancing, adhering to capacity guidelines, engaging outside when possible?) *
Additional comments that will assist with our review of your request:
*

I understand that upon approval of my request, I will be required to provide a negative COVID-19 test to Student Health Services on a weekly basis in order to retain approval.
Should be Empty: