Home » Practicum Learning Contract Practicum Learning Contract This completed electronic form and all faculty and on-site supervisor approvals must be received and approved by the Associate Dean for Calling and Career and the Registrar.Student Name* First Middle Last Student Montreat Email* Student ID* Personal contact # during practicum:*Will this practicum be part of your work-study hours through Montreat College?*NoYesAcademic Major (area of study for the practicum)* This is a...Practicum for 1 Credit Hour (requires 45 on-site hours)Practicum for 2 Credit Hours (requires 90 on-site hours)Practicum for 3 Credit Hours (requires 135 on-site hours)Has Pre-requisite IS 310 been completed?*YesNoIS 310 MUST be completed prior to registering for a practicum.This Practicum will be completed during:*Spring 2021Summer 2021Fall 2021On-site Practicum Supervisor (Coach if EX341)* Email of On-Site Practicum Supervisor* Second On-site Practicum Supervisor if required (Trainer if EX341) Email of Second On-site Practicum Supervisor Will your faculty supervisor be different than your faculty advisor?*NoYesName of Faculty Supervisor* Email of Faculty Supervisor* Organization* Organization's Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Organization's Phone*Organization's FaxThe following dates should be determined in collaboration with your faculty supervisor:Mid-Experience Report Due* MM slash DD slash YYYY Mid-Experience Evaluation Due* MM slash DD slash YYYY Final Assessment Materials Due* MM slash DD slash YYYY On Site Visit Date (proposed)* MM slash DD slash YYYY Final Debriefing Date (proposed)* MM slash DD slash YYYY General description of the Practicum Experience*Summary of the responsibilities and duties of the practicum*In collaboration with your Faculty Supervisor, develop and list 4-6 specific, measurable outcomes or skills you want to achieve in the following areas:Cross-Career Goals (See Manual pp. 8-12 for list of Career Ready Skills desired by all employers and guide to writing specific goals.)*Occupational Goals specific to your major or industry*Outline of Schedules/Responsibilities*INSURANCE: Workers' compensation coverage is provided only if student is being paid for the internship. Montreat College provides only health insurance (for a fee) to its students. Medical Professional Liability in Student Practicum Agreement: Professional Liability: $5 Mil Occurrence. I understand that Montreat College provides health insurance at student rates. I may elect out of the insurance if I have other health insurance coverage. I also know that Montreat College will not provide professional liability or workers' compensation coverage for me. I will be responsible for providing my own insurance if it is not provided by the agency for which I am performing my practicum. If federal work-study monies are paying me while on this practicum, I will be covered by workers' compensation insurance through the College. I must secure the written agreement of the Financial Aid Director/Counselor to verify that I am being paid on work-study funds. AGENCY RESPONSIBILITIES: The agency will provide a learning/working site where the student will be able to accomplish the agreed upon learning objectives in a safe environment free of discrimination and harrassment. DISCRIMINATION: The parties listed on the first page shall not engage in discrimination in the treatment of any participant connected with the internship/practicum. Discrimination means any act that unreasonably differentiates selection and treatment intended or unintended based on age, handicap, national origin, race, marital status, religion, sex, or sexual orientation. SEXUAL HARASSMENT: Sexual harassment is illegal. Sexual harassment includes unwelcome sexual advances and requests for sexual favors. It also includes other verbal or physical conduct of a sexual nature. Sexual harassment is prohibited between the student and any client and is prohibited between the student and the supervisor, and the student and the faculty member. TERMINATION PRIOR TO THE END OF THE PLACEMENT: The agency may request Montreat College to withdraw the student who is not performing satisfactorily or who refuses to follow the organization's administrative and operating policies, procedures, rules, and regulations. The student may request to leave the practicum/internship if he/she believes there are irreconcilable differences or if the student believes he/she is in any danger. In both instances, the professor should be notified immediately and an attempt at resolution should be made. MONTREAT COLLEGE RESPONSIBILITIES: Montreat College is responsible for working with the supervisor and/or agency to place a student who is at the level needed by the agency. The faculty member will make a mid-term contact to discuss how the practicum is progressing. Should there be an issue, the faculty member will attempt to resolve the issue immediately or place the student into another placement and work through any credit hour issues. STUDENT RESPONSIBILITIES: The student will sign up for credit for the internship if that is what the faculty member and the student have agreed upon. The student will treat the position as any job, will completed the assignments as spelled out in this contract, will keep the hours agreed upon by the student and the supervisor, and will notify that supervisor should he/she be absent. The student will keep the advisor informed if there is a potential problem developing. The student will conduct him/herself in a professional manner remembering that this may be a confidential site and treat it as such. In addition to the requirements for the course, the student will keep and sign a time sheet and turn it in to the professor at the end of the term. PUBLIC RELEASE AUTHORIZATION: In order for the agency to use your name, photograph or quotes you must sign a release form and vice-versa. With a signed consent the agency may use these in any form of publicity. If the student is to use information from or about the agency, he/she must have the appropriate consent forms signed by the agency and/or student.Student Electronic Signature* Date* MM slash DD slash YYYY I agree and acknowledge that this document can be executed electronically and it is binding in every way as if signed by my hand. I have read and understand this document. I also acknowledge by signing this contract that an additional fee of $50.00 per credit hour will be charged when registering for either a Practicum or Internship during the fall/spring Academic Year. The tuition rate for Practicum and Internships during the summer will be charged at the rate specified in the Academic Catalog. Payment is due before the start of each semester/term. The student acknowledges that he/she has successfully completed IS 310, Pre-Internship.
