Name Grade
Work-Based Learning
Documentation Checklist
Each student should have the following forms properly signed by the date given to you. These forms are an IMPORTANT part of your work-based learning experience. You will be given a grade of 100 for turning in the forms properly signed by the due date. You will lose points per day per form not returned (signed) on time.
ALL FORMS ARE DUE: Friday, August 9, 2013
1. ______Application (if not already completed)
2. ______Student Information Sheet
3. ______CNET Information Sheet
4. ______Work Permit (if under age 18 – internships included)
5. ______Early Release Agreement (signed by student and parent)
6. ______Insurance Verification Form (signed by student and parent)
7. ______Safety Training Agreement
8. ______Employer Letter (signed by student and employer)
9. ______Training Agreement (signed by student, parent and employer)
10. ______Parent/Guardian Consent Form (signed by student and parent)
11. ______Confidentiality Agreement (signed by student and parent)
12. ______Automobile Insurance Card (copy)
13. ______Health Insurance Card (copy)
14. ______Course Syllabus (signed by student and parent)
15. ______WBL Policies
16. ______WBL Agreement
17. ______WBL Notes
18. ______Last page of Student Handbook – Page 19
(Do not remove from handbook – I will make a copy)
Work-Based Learning Information
Student Information
Last Name / First Name / AddressCity / Zip Code / Home Phone
Birthday / Cell Phone / E-Mail Address
Emergency Contact / Emergency Number / Live with Mom/Dad/Both?
Mom’s Name / Mom’s Address / Mom’s City, Zip
Mom’s Phone / Mom’s Employer / Mom’s Employer Phone
Dad’s Name / Dad’s Address / Dad’s City, Zip
Dad’s Phone / Dad’s Employer / Dad’s Employer Phone
Career Tech Course(s) Currently Enrolled:
Career Tech Course(s) Completed:
Extracurricular Activities (sports, clubs, band, chorus):
CNET INFORMATION SHEET
Graduation Year: ______
Last 4 Digits of SS#: ______
Guidance Counselor: ______
Student’s Program Area of Concentration for Career Pathway (circle one)
Agriscience Pathway
Plant/Science/Horticulture Pathway
Agricultural Mechanics Pathway
Forestry/Natural Resources Pathway
Therapeutic Services – Medical Services Pathway
Therapeutic Services – Nursing Pathway
Transportation Logistical Operation Pathway
Broadcast and Video Production Pathway
Construction Pathway
Metals Technology Pathway
Administrative/Information Support Pathway
Financial Management – Accounting Pathway
Financial Management – Services Pathway
Marketing and Management Pathway
Nutrition & Food Science Pathway
Teaching as a Profession Pathway
Print the following information neatly:
Company Name:______
Company Address: ______
Company Phone #:______
Company Main Contact: ______
Company Fax Number: ______
Company E-Mail Address: ______
Supervisor: ______
Mentor: ______
Job Title: ______
Enter in Starting Hourly Wage: ______
Hourly Wage Now: ______
Work Days (Ex: M-F): ______
Average Hours Per Week: ______
Work Hours (Ex: 8AM – 5PM): ______
Enter First Date of Employment: ______
Instructions for Obtaining a Work Permit
To access the online employment certificate (work permit) system, go to the website at www.dol.state.ga.us.
· Select “Child Labor”, listed under “Quick Links”.
· Select “Get a Youth Employment Certificate (Work Permit)”.
SECTION A – To be completed by the Minor
To start a work permit online, the minor:
· Selects the “Minor” option.
· Enters Social Security Number or Parent Alien Certification number (for minors under 15), date of birth, and then selects “Submit”.
· Enters name, address, parent’s name, etc.
· Ensures all fields are completed.
· Verifies all information and selects “Submit”.
· Minor will receive a 10 character “Minor Security Key (MSK)”.
Print the “Work Permit Data Sheet” and take it to the potential employer
Take the Work Permit Data Sheet to your employer
Employer will complete appropriate section
Return the Work Permit Data Sheet and a copy of your Birth Certificate to Mrs. Cortney Roberts at Worth County High School. She is located in the CTAE office.
Early Release Agreement
We are delighted your son/daughter has enrolled in a Work-Based Learning Program. We believe you will find the experiences your son/daughter has this year in the classroom and at the job site will be beneficial to him/her for the rest of his/her life. The purpose of these work-based learning programs is to provide students the opportunity to connect what they learn in school with work-site application in order to enable a smooth transition into the work force and/or postsecondary education after graduation from high school.
As a member of the work-based learning program, your son/daughter will be leaving school in order to go to work. He/she will receive a unit of credit per release period for this program.
It is the student’s responsibility to be in class every day. He/she is not to go to work without first going to school, nor go to school without going to work without prior approval from the work-site coordinator. The student is also responsible for following the school’s attendance policy. He/she may have no more than eight absences per year. If he/she is absent more than eight days per year from school, then he/she must apply for an attendance waiver for the Work-Based Learning Program before credit may be granted.
In addition to the on-the-job training and classroom instruction, a third component of the work-based learning program is the related career technical student organization. These organizations are an integral part of the work-based learning programs at each school. Students will gain important leadership and social skills as well as a sense of responsibility to the school and the community. Dues include membership at the local, state, and national levels. Work-based learning students are strongly encouraged to participate.
We look forward to a successful year working with your son/daughter. If you have any questions concerning the program, please don’t hesitate to call the work-based learning coordinator.
It is understood that my son/daughter is being released early from school for the purpose of working at a paying job or an unpaid internship. In accepting the privilege of an early release, we agree to the following stipulations:
Ø The parents/guardians will arrange and be responsible for transportation for the student to and from work.
Ø The school assumes no responsibility for the student’s safety.
Ø The student will leave the building and campus immediately after release from class.
Ø If, for any reason, transportation is unavailable on any day, the student will go directly to coordinator’s room and remain there until transportation become available or school is dismissed.
Ø The student must continue employment and will notify the instructor if employment is not continued.
Ø The student must maintain a “C” average, pass required courses, and have good school conduct.
Ø If any of the above stipulations are violated, or if the school considers termination of this privilege in the best educational interest of the student, the privilege may be revoked.
Parent/Guardian Signature:______Date:______
Student Signature:______Date:______
Work-Based Learning Program
Early Release Understanding and Insurance Verification Form
Directions: For a student to be enrolled in the program, the parent/guardian must provide the required information below and sign and date the form at the bottom of the page.
Early Release
I understand that my child, ______, is enrolled in the work-based learning program at Worth County High School and that my child will be dismissed from school at the end of his/her regularly scheduled on-campus classes each day.
I assume full responsibility for my child after dismissal from school, including days when my child is not required to be on the job. I also understand that my child must be covered by automobile accident and health insurance in order to drive to and from work and to be a part of the work-based learning program. (Please complete information section below). ______Parent/Guardian Initials
Automobile Accident and Health Insurance
I understand that my child must be covered by automobile accident in order to participate in the work-based learning program. I understand that it is important for my child to be covered by health insurance. I have checked the appropriate statement regarding insurance coverage for this school year. I agree to notify the work-based learning coordinator if this coverage changes during the school year.
Automobile Accident Insurance
My child is covered by automobile accident insurance through the following provider:
Provider ______Policy Number ______
Address ______City/State/Zip ______
Name of Insured ______Phone Number ______
Health Insurance
o My child has no health insurance coverage
o My child is covered by health insurance purchased through the school
o My child is covered by health insurance through the following provider:
Provider ______Policy Number ______
Address ______City/State/Zip ______
Name of Insured ______Phone Number ______
Safety Training Agreement
______, a student in the Work-Based Learning Program at Worth County High School and an employee/intern at ______has completed the necessary safety training for the current position of employment. The employer certifies that the proper procedures related to the job requirements have been shown to the student and that in the case of an emergency, the student has been given instructions on what to do to resolve the situation. The student understands that failure to comply with these safety procedures may result in personal injury or in injury to others. The student agrees to follow all the safety rules and regulations of the current employer.
Student’s Signature: ______Date: ______
Employer’s Signature: ______Date: ______
Parent/Guardian’s Signature: ______Date: ______
WBL Coordinator’s Signature: ______Date: ______
Dear Employer:
On behalf of the Work-Based Learning Program in Worth County, I would like to thank you for your willingness to work with and evaluate our students.
At the beginning of school, there are a number of forms that the school must have on file for these student since they are receiving the same unit of credit for this course as English, Math, etc. Each student will need to have this letter, an early release understanding/insurance verification form, a training agreement, and an initial training plan signed and on file. These four forms will require your signature.
The training agreement explains what is expected of all parties involved in this cooperative training program and the training plan identifies tasks that the student is now performing or learning on the job.
In the past, we have had a slight problem with excessive absences from school with some students. We realize this is not your concern; however, we would like to solicit your help to remedy this problem. A student who is absent from school for the day is not supposed to participate on the job for that day. If a student is absent, I may call you to confirm whether or not the student reports to work.
If the student has reported to work, I will deal with the situation according to the program policies. I have informed the students that it is their responsibility to adhere to this policy and I appreciate your cooperation in this matter. Hopefully, working together, these students will become more productive and dependable employees and citizens of the community.
Each grading period, the student or I will bring a job evaluation form to you to be completed. You should be able to fill it out in approximately five minutes. Your comments about the student-employee are always important.
Thank you in advance for your cooperation. I hope you will find that students in the Worth County Work-Based Learning Program do an excellent job for you. Please feel free to call if you have any questions.
Sincerely,
Tina Pate
Work-Based Learning Coordinator
229-206-2400 – Cell
229-777-8414 – Office
Employer Signature:______Date: ______
Student Signature:______Date: ______
WORTH COUNTY HIGH SCHOOL
WORK-BASED LEARNING PROGRAM
Training Agreement Form
Student Name ______Job Title ______
Business ______Phone ______
Supervisor ______Title ______
Training Period Begins ______
The Student Agrees:
1. To be at least 16 years of age and to have a Social Security number available for the employer.
2. To secure a work-permit if under 18 years of age.
3. To assist the Work-Based Learning Coordinator in finding an appropriate employment position related to the career focus area of the program and the career objective of the student.
4. To provide transportation to and from work.
5. To attend school and work regularly and not go to work without first going to school, or go to school without going to work, unless previously discussed with the Work-Based Learning Coordinator. Failure to adhere to this part of the agreement may result in the student receiving appropriate academic and/or disciplinary action. If a student will be absent from school or work, the Work-Based Learning Coordinator should be notified as soon as possible.
6. To discuss all aspects of the employment with the Work-Based Learning Coordinator and the worksite supervisor—not with other students, coworkers, etc.
7. To represent the school and employer by demonstrating honesty, punctuality, courtesy, and a willingness to learn. If the student is dismissed from employment due to negligence or misconduct, proved by school investigation, the student will be dropped from the Work-Based Learning program as well as receiving a failing grade for the work-based learning program.
8. To make employment changes only with the approval of the Work-Based Learning Coordinator. The Work-Based Learning Coordinator reserves the right to change the student’s employment situation if necessary.
9. To be evaluated by the work-based learning coordinator and the Work-Based training supervisor a minimum of once per grading period.
10. To submit to the Work-Based Learning Coordinator a weekly record indicating activities engaged in at the worksite and total hours and salary earned during the week.
11. To adhere to the school’s attendance policy not being absent more than 8 days per year. If absent more than 8 days per year from school, the student must apply for an attendance waiver for the work program.
The Parents/Guardian of the Student Agree:
1. To encourage the student to carry out effectively his/her duties and responsibilities at both the school and place of employment.
2. To assume responsibility for the conduct and safety of the student from the time he/she leaves school until he/she reports to work; likewise, from the time he/she leaves his/her job until he/she arrives home.