2024-2025 Work-Based Learning Permission Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student Cell Number*

Please enter a valid phone number.

Student Personal Email*

example@example.com

Emergency Contact Name*

Emergency Contact Phone Number*

High School*

BHPPHSPVHSWHS

Date of Birth*

Date

Gender*

Career Center Program*

Career Center Instructor*

Please list any allergies or other medical information. If none, type "none".*

Company Name:

Current/Potential Employer's/ Supervisors Name

First NameLast Name

Employer/Supervisor Contact Number

Please enter a valid phone number.

Employer/ Supervisor Email

example@example.com

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Start Date

End Date

What days will you be working

Student Guidelines/Responsibilities:

Students that are given the opportunity to participate in a Work-Based Learning experience are required to have passing grades (at ACTC and high school), a good discipline record, and good attendance. I also understand that during my internship the STC representative will review this information periodically. If there are any problems that arise during the internship period (for example: failing grades, discipline problems, poor attendance) I will be asked to return to ACTC and not be able to participate.

I agree to the following

I have no outstanding fees due at ACTC.
I will dress appropriately for the workplace.
I will exhibit good manners & professional behavior.
I will report to work on time and on the days agreed upon.
I will remain at the worksite for the length of time specified on the agreement form.
I will follow all safety rules & regulations at the worksite.
I will notify Mr. Guthrie or Mrs. Riddle if I am hurt or injured at the worksite.
I will notify Mr. Guthrie or Mrs. Riddle of any absences from school and/or work.
I will not stay home from school and then report to the worksite without permission from Mr. Guthrie or Mrs. Riddle.
I will submit all necessary information on time for my co-op grade.
I will follow all HIPAA regulations in accordance with my placement.

By signing below, the student agrees to the rules stated above and understands that participation in this program is a PRIVILEGE and may be terminated if guidelines are not followed.

Student Signature*

Date*

Date

Parent/Guardian - PLEASE READ

My child has discussed the Work-Based Learning Program with me, and I give my permission to have them participate in the program. I understand that my child is responsible for their own transporation and Accident Insurance to and from the worksite. I also give my permission to receive emergeny medical treatment in case of injury or illness.

I understand that school personnel will not be present when the student is at the worksite and will not be responsible for my child. The district shall not be liable for any injuries sustained by the student's participation in this program. I understand there may be various risks associated with the work-based learning environment; however, I give consent for my child to participate despite these risks.

Parent Email *

example@example.com

ACTC will provide Workers Compensation and Liability Insurance for students participating in a Work-Based Learning experience.

This agreement may be terminated after consultation with the coordinator, for due cause, or for unforeseen business conditions.
The worksite shall conform of all federal, state, and local labor laws.
Students will be accepted and assigned to worksite without regard to race, color, national origin, sex, handicap, or disadvantage.

Permission Form

Employer Information