Keene State College SPECIAL PERMISSION FORM PRACTICUM, INTERNSHIP, EXTERNSHIP, FIELDWORK

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1 Keene State College SPECIAL PERMISSION FORM PRACTICUM, INTERNSHIP, EXTERNSHIP, FIELDWORK DEPARTMENT NUMBER (Official use only) CREDITS COURSE TITLE: STUDENT NAME: (print) TERM: ID#: COURSE OUTLINE: Description of Experiential Learning Placement for practica, field experiences, externships, and internships. Attach separate sheet if necessary. COURSE OBJECTIVES / LEARNING OUTCOMES: List the academic learning outcomes for this placement JOB DESCRIPTION Describe the potential duties, tasks, deliverables, and responsibilities of the position including supervision provided, and how the student will be evaluated. ASSIGNMENTS & EVALUATION CRITERIA List required assignments and grading criteria. Include timeline for assignments and completion. Student (print) Student s Signature Faculty / Instructor (print) Instructor s Signature Department Chair (print)* Department Chair* Please return this completed and signed form to Karen Balnis, Service Learning and Internship Coordinator, Elliot Center, Academic and Career Advising, room 122E. Copies will be ed to Faculty and Students. *The Director of Continuing Education may fulfill the role of department chair for summer courses. Special Permission Internships - Student Learning Agreement docx page 1 of 5

2 Student Name: School Address: PLACEMENT INFORMATION TO BE COMPLETED BY STUDENT WITH INFORMATION FROM THE ONSITE SUPERVISOR Student ID#: Home Address: Phone#: Emergency Contact Name: Emergency Phone#: Major: Faculty Sponsor: Faculty Placement Site/Employer: Placement Address: On-site Supervisor: Title: Supervisor s phone#: Supervisor s Student s position/title: Salary / Compensation: unpaid* -or- $ hourly rate Semester s work start date: Semester s work end date: Estimated hours per week at site: *UNPAID INTERNSHIPS The following is based on a 2015 Supreme Court ruling. If the employer doesn t meet these criteria, the intern should be paid at least the minimum wage. In determining the legitimacy of unpaid internships, consider the extent to which: 1. The intern and the employer clearly understand that there is no expectation of compensation. 2. The internship provides training similar to that which would be given in an educational environment, including the clinical and other hands on training provided by educational institutions. 3. The internship is tied to the intern s formal education program by coursework and/or the receipt of academic credit. 4. The internship accommodates the intern s academic commitments by corresponding to the academic calendar. 5. The internship s duration is limited to the period in which provides the intern with beneficial learning. 6. The intern s work complements, rather than displaces, the work of paid employees while providing significant educational benefits to the intern. 7. The intern and the employer understand that the internship is conducted without entitlement to a paid job at the conclusion of the internship. Special Permission Internships - Student Learning Agreement docx page 2 of 5

3 Student Statement of Understanding: By signing below, I agree to complete the course requirement specified in this learning placement description and, if necessary, to inform my faculty sponsor of any changes or difficulties which might affect satisfactory completion of the experience. I acknowledge that once I have registered for this practicum/fieldwork/internship placement, I cannot withdraw from the placement and that failure to complete the objectives within the designated work period will result in a failing grade. In addition I have read, understand, and signed the Liability Release and Student Transportation Policies. STUDENTS: SIGN BELOW, COLLECT THE REQUIRED SIGNATURES AND RETURN TO THE KSC SERVICE LEARNING AND INTERNSHIP OFFICE. Student Signature: Faculty Signature: On-Site Supervisor Signature: The following pages contain student liability documents. Students must complete both the liability and travel waiver. A separate Affiliation Agreement should be on file in the Service Learning and Internship office. Contact to determine if forms are on file. For office use only Affiliation Agreement on file: NH DOL form completed. (unpaid internships only) Karen Balnis Service Learning and Internship Coordinator Academic and Career Advising Keene State College 229 Main Street, MS 2602 Keene, NH Fax Special Permission Internships - Student Learning Agreement docx page 3 of 5

4 KEENE STATE COLLEGE: LIABILITY RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE This is a legally binding Release, Waiver, Discharge and Covenant Not to Sue (collectively, Release ), made voluntarily by me, the undersigned Releasor, on my own behalf, and on behalf of my heirs, executors, administrators, legal representatives and assigns (hereinafter collectively, Releasor, I or me, which terms shall also include Releasor s parents or guardian, if Releasor is under 18 years of age) to Keene State College ( KSC ). As the undersigned Releasor, I fully recognize that there are dangers and risks to which I may be exposed by participating in this supervised practice for completion of the program/course requirements. As the undersigned Releasor, I understand the risks of this required academic program. With informed consent, and for valuable consideration received, including assistance provided by KSC, as the undersigned Releasor, I agree to assume and take on myself all of the risks and responsibilities in any way arising from or associated with this activity, and I release KSC and all of its affiliates, divisions, departments and other units, committees and groups, and its and their respective governing boards, officers, directors, principals, trustees, legal representatives, members, owners, employees, agents, administrators, assigns, and contractors (collectively Releasees ), from any and all claims, demands, suits, judgments, damages, actions and liabilities of every name and nature whatsoever, whenever occurring, whether known or unknown, contingent or fixed, at law or in equity, that I may suffer at any time arising from or in connection with the Activity, including any injury or harm to me, my death, or damage to my property (collectively Liabilities ), and I agree to, indemnify, and save Releasees harmless from and against any and all Liabilities. As the undersigned Releasor, I recognize that this Release means I am giving up, among other things, all rights to sue Releasees for injuries, damages or losses I may incur. I also understand that this Release binds my heirs, executors, administrators, legal representatives and assigns, as well as myself. I also affirm that I have adequate medical or health insurance to cover any medical assistance I may require. I agree that this Release shall be governed for all purposes by New Hampshire law, without regard to such law on choice of law. I have read this entire Release. I fully understand the entire Release and acknowledge that I have had the opportunity to review this Release with an attorney of my choosing if I so desire, and I agree to be legally bound by the Release. THIS IS A RELEASE OF YOUR RIGHTS, READ CAREFULLY AND UNDERSTAND BEFORE SIGNING. Releasor s Signature (Student) Print Name _ Parent s Signature (if releasor is a minor) _ Print Name Special Permission Internships - Student Learning Agreement docx page 4 of 5

5 KEENE STATE COLLEGE ACKNOWLEDGEMENT - STUDENT USE OF PERSONAL VEHICLE FOR OFF-CAMPUS EDUCATIONAL EXPERIENCES Student Transportation The richness of a Keene State College education may be enhanced through the participation in one or more educational experiences. These experiences are both curricular and co-curricular and may take place on or off campus. Several degree programs include one or more of these experiences as a graduation requirement. Students should check with their advisor and/or department chair to determine if this is a requirement for their major area. If the experience is to be convened at a remote location, students may be required to provide their own transportation to and from the site. Unless specifically stated, Keene State College and the University System of New Hampshire assume no responsibility for transportation of students to the site of an experience. Students participating in an off-campus educational experience will be responsible for all costs related to travel. Personal vehicles should be adequately insured for public liability insurance protection. Students are responsible for insuring their own vehicles. Students will not be reimbursed by USNH for collision losses that occur during business use of a personal vehicle. In the event of an accident, the owner's personal insurance provides coverage and the owner is personally responsible for any deductible payable. USNH does not provide any coverage for comprehensive or collision insurance for personal vehicles. I acknowledge that I have read and understand the student transportation policies and will abide by them. Student Name - Signature Student Name - Printed Special Permission Internships - Student Learning Agreement docx page 5 of 5

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