CHS WBL Student and Parent Agreement
Fall 2023
Today's Date
-
Month
-
Day
Year
Date
Name
First Name
Middle Name
Last Name
Name that you go by:
Birthdate
-
Month
-
Day
Year
Date
2022-2023 Grade Level
10th -Sophomore
11th-Junior
12th-Senior
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Phone Number where student can be reached:
-
Area Code
Phone Number
Parent/Guardian Name
Parent/Guardian Email Address
example@example.com
Parent/Guardian Cell Phone#
-
Area Code
Phone Number
Career Information
Current career Interest:
What are your plans after high school?
Employment Information
Where are you employed?
Place of Employment's Address
Internship Start Date
Internship End Date
Place of Employment's Phone Number
-
Area Code
Phone Number
How long have you been employed at this business?
Is this internship related to your Career major at CHS?
Yes
No
What Career and Technology Program are you in that is directly related to your job?
Agricultural Science
Automotive Technology
Building Construction
Business, Marketing and Web Design
Culinary Arts
Early Childhood Education
Emergency and Fire Management Services
Family & Consumer Science
Health Science
Media Technology (Video Production)
Pre-Engineering & Mechanical Design
Sports Medicine
Utility Line Worker
Welding
What is the latest course in this program that you have completed?
Is your Internship placement aligned with your IGP or Career Major/Interest? If not, that portion of your IGP will need to be adjusted.
Yes
No
Who is your immediate supervisor?
What is your supervisor's title (Example=owner. manager, etc)
Supervisor's Email
example@example.com
Supervisor's Work Phone Number
Is this Internship paid or unpaid?
Paid
Unpaid
Please list your duties:
Are you receiving a course credit at school for this internship?
Yes. WBL is listed on my schedule or will be soon once a schedule change is made by my counselor. I understand that I must work a minimum of 120 hours in order to receive the course credit.
No, I am not receiving a course credit for this internship but I do understand that by working a minimum of 40 hours, I will meet the State of South Carolina's requirement of being College or Career Ready upon graduation.
Please list any allergies or medical conditions that would be used in an emergency:
General WBL Requirements
Students:
Must be 16 years of age
Must provide their own transportation
Must maintain regular attendance at the work-site
Must maintain good grades, attendance and discipline at school
Communicate with the WBL Coordinator if the internship interferes with academic success
Notify WBL Coordinator prior to resigning from internship position
Turn in all required forms, time sheets, etc (whether electronic or paper) on time.
Understand that quitting will result in being dropped from the WBL program
Understand that being fired will result in being dropped from the WBL program
Parents will:
Be supportive of and encouraging of a positive experience through this internship.
Communicate with the WBL Coordinator if the internship interferes with academic success.
Notify WBL Coordinator prior to their student resigning from internship position.
Notify the WBL Coordinator if there are any concerns.
CSD will:
Designate a coordinator to assist the student and employer and provide guidance.
Provide Worker's Compensation Insurance
The Employer will:
Provide a safe working environment for all employees.
Appoint a training supervisor for the student and facilate the training.
If the internship is paid, pay the student at least current minimum wage and conform with all local, state and federal laws.
Assess the student's progress via regular evaluations sent by the WBL Coordinator and provide the student with a variety of experiences.
Permit a school representative to visit the supervisor and student at the work site.
Notify the WBL Coordinator promptly with conditions or concerns regarding progress of the student or upon termination.
Student
Please sign via e-signature below:
I certify that the answers given are true and complete to the best of my ability and any false or misleading information given on this application or verbally to the WBL Coordinator and my employer may result in the dismissal from the WBL program wi If I quit my job without prior approval from the WBL Coordinator. I also understand the requirements for entering the Work-Based Learning Program and for maintaining my eligibility throughout the year.
Parent/Guardian:
Please sign via e-signature below:
My child has my permission to participate in the CHS Work-Based Learning Program. I understand that I will be responsible for arranging transportation to and from the work site. I also understand that school personnel will not be present on the site and thus, will not be responsible for my child. In the event of any injuries sustained by the student’s participation in this program, I will not hold Clover School District liable. I also consent for the WBL Coordinator to contact my child concerning due dates for work hours, and any other school related matters via email, website and other professional methods of communication. I also consent for my child to receive emergency medical treatment in the event of an injury or illness.
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