PennDel School of Ministry | Ministerial Internship Confirmation Form

MINISTERIAL INTERNSHIP CONFIRMATION FORM "YELLOW SHEET"
*** PDSOM Updated 11/01/2022 *** This form MUST be filled out completely and submitted for approval PRIOR TO registering online for the class and beginning your internship. This form is to be completed together WITH your mentor.
INTERN INFORMATION
Intern's Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Intern's Home Church*
Pastor/Mentor Name*
First Last
Check which level you are pursuing at this time:*
NOTE: Pastor/Mentor credential level needs to be one level above the student, unless the credential level is Ordained. Ex (Student is pursuing CERTIFIED Credential; Pastor/Mentor should be at least LICENSED.)
Intern Signature*
By signing your name electronically above, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this Internship Form.
Date*
Date Format: MM slash DD slash YYYY

Mentor Information
Pastor/Mentor's Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Church Name Where Internship Will Be Performed*
Church Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you currently credentialed with the Assemblies of God?*
- Yes
- No
What level of credential do you hold?*
- Certified
- License
- Ordained
As the mentoring pastor/coach I will meet with, pray with, encourage, correct, guide, and assist my intern to develop in the most Godly fashion, the character of a servant leader. I realize this will take time and effort on my part, as well as the intern's part. I further realize I will receive an Internship file to download and print out to use as a guide for the intern and I (Please print out a copy for yourself to keep.)*
- I agree

INTERN & MENTOR
Important Notice: The following information must be filled out, signed, initialed, and dated TOGETHER by BOTH the INTERN & MENTOR.
Internship Start Date*
Date Format: MM slash DD slash YYYY
Intern Initials*
Mentor Initials*
Internship Completion Date*
Date Format: MM slash DD slash YYYY
Intern Initials*
Mentor Initials*

Ministerial Internship Confirmation Form - "Yellow Sheet"