INTERNSHIP PROGRAM SIGNATURE FORMS

These forms are required for students to participate in the [Name of School] Internship Program. They must

be completed, signed by the student intern and his/her parent or guardian, and submitted to the School Internship Coordinator.

DUE DATE:

STUDENT INTERN’S NAME: _________________________________________________________________

EMAIL: _________________________________ CELL NUMBER: ________________________________

SCHOOL INTERNSHIP COORDINATOR’S NAME: _______________________________________________

ROOM #: _________________

[Company]

[Street Address, City, ST ZIP Code]

Tel [Telephone] Fax [Fax]

[Email]

[Website]

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INTERNSHIP PROGRAM OVERVIEW

The Internship Program is designed for career exploration that benefits the student and will be tailored to meet the unique needs and interests of the learner. The student will participate in a workplace experience while interning with a mentor in a business/organization, which is reflective of the student’s career interest, while observing workplace functions and investigating the requirements of a specific career field. Essential career skills will be correlated with soft skills and academic skills in a project-based format. The student will be released from school Monday-Thursday during practicum period(s) to intern with their mentor in an unpaid position with a business/organization an average of four hours per week for ½ credit or eight hours per week for 1 credit. Every Friday the student will participate in Internship Seminars during practicum period(s) at school instead of working with their mentor at the internship site. Seminars will assist the student in making connections between academic learning and workplace experiences in the following areas:

• Academic application, competency, and relationship development in a professional setting

• Career exposure, professionalism, and organizational culture

• Performance evaluation in light of expressed goals and learning outcomes

• Self-perception as compared to professional perception of site mentor

• Career goal assessment and clarification through reflection on internship experience

• Career Portfolio development, networking, and social media

WRK 141/142 INTERNSHIP PROGRAM (Semester ½ Credit or 1 Credit (Yearly 1 Credit or 2 Credits) (12) Prerequisite: The Career Exploration course is a prerequisite or co-requisite to the Internship Program. Administrative approval is required.

PARENT/GUARDIAN CONSENT FORM

This form gives permission for your son/daughter to participate in the Internship Program and acknowledges that each student is responsible for his/her transportation to and from the Internship Site.

PERMISSION TO PARTICIPATE

I give my permission for _______________________________________________ to participate in the Internship Program. (name of student)

PERMISSION TO TRAVEL

As the parent/legal guardian of the above named student, I hereby consent that he/she may drive a private vehicle to and from the Internship Site. I acknowledge that he/she is licensed to drive under the laws of the State of Illinois and agree to advise the school immediately if his/her driving privileges are suspended, revoked, or have expired without a timely renewal. I understand that automobile insurance is required.

YES NO I will transport my child to and from the Internship site.

VEHICLE VERIFICATION

Driver’s License Number: _______________________________________________ Expiration Date: ________________

Vehicle Make/Model: ____________________________ Year: ________ License Plate: _________________________

Insurance Company: _____________________________________ Policy Number: ______________________________

___________________________________________________________________________________________________________________________

Signature of Parent/Guardian Date

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MEDICAL AUTHORIZATION AND INSURANCE INFORMATION

Your child wishes to participate in the off-campus Internship Program. Such participation will require training from and on the premises of a participating community mentor. As a participant, your child will receive no wages for training time and may not be protected by the Workmen’s Compensation laws of the State of Illinois for any injury or illness incurred as a result of his/her onsite training. Because of this exposure, it is recommended that all participants in the off-campus Internship Program be adequately covered by hospital/medical insurance. As a condition of participation, your child must have medical insurance coverage.

Should it be necessary for my son/daughter to have medical treatment while participating in this program, I hereby give the school corporation and/or the Internship Site personnel permission to use their best judgment in obtaining medical services for my child, and I give permission to the physician selected to render whatever medical treatment he/she deems necessary and appropriate.

YES NO

Permission is also granted to release emergency contact/medical history to the attending physician or to the Internship Site personnel, if needed:

YES NO

Health Insurance Company: _________________________________ Name of Policy Holder: ______________________

Identification Number: _____________________________________ Account Number: ___________________________

Emergency Contact #1: ____________________________________________ Phone: ____________________________

Emergency Contact #2: ____________________________________________ Phone: ____________________________

Family Doctor: ___________________________________________________ Phone: ____________________________

Does your son/daughter require any special accommodations due to medical limitations, disabilities, or other restrictions?

YES NO

If yes, please explain:

I hereby agree to waive and release any and all rights that I, my child, or our representatives, may have to make claim against the school corporation and the Internship Site of my child, or their respective officers, employees, or representative arising from injury or damages, including attorney fees that may result from my child’s participation in the Internship Program.

I further agree to indemnify and hold harmless the school corporation and the Internship Site of my child, or their respective officers, employees, or representative from any claims, including attorney fees, which I or my child might make or which might be made on my or our behalf by others, or which might be made against me or my child by others, arising from my child’s participation in the internship Program.

___________________________________________________________________________________________________________________________

Signature of Parent/Guardian Date

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INTERNSHIP PROGRAM – CODE OF CONDUCT

Each student participating in the Internship Program must agree to abide by the following Code of Conduct regulations.

1. Adhere to all of the expectations as outlined in the [Name of School] Handbook at school and at the internship site.

2. Understand that all infractions including smoking, drug or alcohol use, or other illegal acts at the Internship Site will have the same consequences as if that behavior were conducted on school property.

3. Comply with the policies, procedures, dress code, behavior guidelines and safety rules of the Internship Site.

4. Maintain confidentiality guidelines at the Internship Site and at school.

5. Participate in approved activities structured by the School Internship Coordinator and the Internship Site Mentor, focusing on the Internship Program Agreement.

6. Demonstrate appropriate business etiquette, honesty, punctuality, respect, courtesy, cooperative attitude, proper health and grooming habits, and a willingness to learn both at the internship site and in the seminars/classes.

7. Understand that the business is not liable for accidents or injuries sustained at the Internship Site.

8. Fulfill the commitment of the Internship Program Agreement by remaining at the internship site for the agreed upon time period except by mutual agreement of all parties.

9. Abide by the assigned internship site weekly schedule (days/hours) except by mutual agreement of all parties.

10. Notify the School Internship Coordinator and Internship Mentor if unable to report to internship site or seminars/classes.

11. Attend Friday seminar classes each week.

12. Complete the required number of internship hours each semester as listed below: 1 period = 200 minutes per week

2 periods = 400 minutes per week

13. Complete & submit all documentation as directed by the Internship Coordinator.

14. Complete weekly reports and assignments in a timely manner; failure to do so may result in being taken off the Internship Site to remain at school to meet these obligations.

15. Agree to not falsify any Internship records, forms or documents.

16. Understand that participation in the Internship Program does not excuse me from obligations to any teacher and that students may be taken off the Internship Site and remain at school to meet these obligations, whether they are failures, incomplete assignments, detentions, absences, or tardiness.

17. Realize that students in the Internship Program follow the school calendar, and as such, attendance at the internship site is not required on non-school days. Student interns will always follow the school’s daily bell schedule.

18. Reporting to the internship site on days absent from school or during a suspension is not allowed. (This will require the students to modify Internship hours accordingly on alternate schedule days and notify the mentor of such.)

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19. Being terminated from the student’s internship site due to an illegal act, absenteeism, lack of cooperation etc., may result in being dismissed from the Internship Program with the status of Failure (F) on the student’s permanent transcript.

20. Violating any regulation(s) stated within the Internship Code of Conduct Contract may result in dismissal from the Internship Program with the status of Failure (F) on the student’s permanent transcript.

I fully understand and agree to abide by all regulations stated in this Internship Program Code of Conduct.

Student Signature as Indication of Commitment Date

Parent/Guardian Signature as Indication of Support Date

INTERNSHIP CONFIDENTIALITY AGREEMENT

I understand that in the course of my internship experience that I may have access to and be involved in the processing of verbal, written, computer generated, computer accessed, filmed, and/or recorded information related to clients, employees, and staff or the organization or business.

I understand that I am required to maintain confidentiality of this direct or indirect information at all times, both during and after my internship experience. I understand that I will not share, discuss, or reveal any of this information with anyone.

I understand that any breach of confidentiality may result in disciplinary action, including termination from the Internship Program (with the status of ‘Failure’ placed on my permanent transcript) or legal action.

I certify by my signature that I acknowledge being informed of the confidentiality policy concerning confidentiality information or its treatment. I agree to adhere to and uphold the private and privileged information therein.

Student Intern’s Name: ______________________________________ Signature: __________________________________

(Full Legal Name Printed)

Witnessed By: _____________________________________________ Date: ______________________________________

(School Internship Coordinator or Internship Site Supervisor/Mentor)

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INTERNSHIP PROGRAM AGREEMENT

The Internship Program Agreement is a separate document which will require signatures at a later date. It will be completed once a suitable internship experience has been approved by the School Internship Coordinator. In addition to providing contact information, internship position description, schedule and goals, it outlines the arrangement between school and the internship site on the conditions of the opportunities available to the student intern while at the internship site. As reference, highlights from the agreement are provided below.

THE STUDENT and/or PARENT/GUARDIAN AGREES TO: 1. Adhere to all of the expectations as outlined in the high school handbook and at the internship site. 2. Provide your own transportation to and from the internship site. 3. Assume all responsibility, accountability, and liability for any and all acts arising out of the student’s participation in the internship

program, including but not limited to the operation of a motor vehicle to and from the internship site. 4. Acknowledge that the student intern will receive no wages for time at the internship site. 5. Recognize that the student intern may not be protected by the Workmen’s Compensation laws of the State of Illinois for any injury or illness

incurred as a result of his/her onsite training. The School does not provide liability insurance coverage for Internship Program students. If liability insurance coverage is required by the participating business/organization, it is the responsibility of the student to provide documentation of coverage.

6. Abide by the assigned internship site weekly schedule (days/hours) except by mutual agreement of all parties. 7. Realize that students in the Internship Program follow the school calendar, and as such, attendance at the internship site is not required on non-

school days. Student interns will always follow the school’s daily bell schedule. 8. Recognize that reporting to the internship site on days absent from school or during a suspension is not allowed. This will require the students to

modify Internship hours accordingly on alternate schedule days and notify the mentor of such. 9. Arrive on time daily for both school and internship and if late or absent for reasons beyond student’s control, call the appropriate personnel. 10. Attend any necessary training sessions, all seminars, and complete all assignments in a timely manner. 11. Complete an internship site project, career portfolio, and capstone presentation. 12. Accept that any breach of confidentiality may result in immediate dismissal. 13. Grant consent to be photographed for educational and promotional purposes (video, brochures, articles.) 14. Understand that being terminated from the internship site due to an illegal act, absenteeism, lack of cooperation etc., may result in being dismissed

from the Internship Program with the status of Failure (F) on the student’s permanent transcript. 15. Comprehend that violating any regulation(s) stated within the Internship Code of Conduct Contract may result in dismissal from the Internship

Program with the status of Failure (F) on the student’s permanent transcript. 16. Realize that parents/guardians should communicate questions/concerns directly to the school coordinator, not the internship site mentor. 17. Abide by all implied and stated terms included in this agreement.

THE INTERNSHIP SITE AGREES TO: 1. Assign an individual employee as the student’s mentor. 2. Understand the internship is to benefit the student in career exploration and the student intern is not entitled to wages for the time spent

in training and should not displace regular employees. 3. Provide the student with meaningful work assignments which, within the confines of employer needs and time-tables, will enhance and

complement the student’s academic program. 4. Provide the student with an orientation to the work setting, including confidentiality, and emergency & safety procedures, upon initiation

of each new internship experience, as appropriate. 5. Provide safe and healthful working conditions for the student and hold the School harmless for any injury, illness or damages resulting directly or

indirectly from the student’s employment activities. 6. Provide students to the extent possible, an overview of all applicable aspects of the industry including organization and management structure,

technical and production processes, and major industry, labor, health, environmental, and community issues impacting the business. 7. Notify the School if you are aware that there is a sex offender employed at the internship site. 8. Understand that the student intern will follow the school schedule on alternate schedule and inclement weather days. 9. Evaluate the student’s work performance at least twice during each internship experience. 5. Communicate questions and concerns directly to the school internship coordinator. 6. Abide by all implied and stated terms included in this agreement.

THE SCHOOL SYSTEM AGREES TO:

1. Provide a school internship coordinator to work with businesses, schools, and the community. 2. Provide organization/business with appropriate personal and academic information on qualified student applicants, upon written

authorization by the parent/guardian. 3. Coordinate efforts of program participants including students, parents, teachers and business mentors. 4. Monitor the safety and security of the internship site, coordinating with the business mentor. 5. Maintain documentation; internship site placements, mentors, student hours, student evaluations, and correspondence with students, parents,

and business mentors. 6. Abide by all implied and stated terms included in this agreement.