Experiential Education learning agreement
For Service Learning or Practicum Courses
DEPARTMENT / COURSE NUMBER / CREDITS
COURSE TITLE: / TERM:
FACULTY:
(print)
STUDENT NAME:
(print) / ID#:
COURSE OUTLINE: Description of Experiential Learning Placement for service learning, internships, field experiences and practicums. May attach separate sheet.)
COURSE OBJECTIVES / LEARNING OUTCOMES:
List the academic learning outcomes for this placement
PLACEMENT DESCRIPTION
Describe the tasks and responsibilities of the placement including supervision provided.
ASSIGNMENTS & EVALUATION CRITERIA
List required assignments and grading criteria. Include timeline for assignments and completion.
Please send this form to Karen Balnis, Service Learning and Internship Coordinator, MS 3535
PLACEMENT INFORMATION TO BE COMPLETED BY STUDENT
WITH INFORMATION FROM THE ONSITE SUPERVISOR
Student Name: / Student ID#:
School Address: / Home Address:
Phone#: / Email:
Emergency Contact Name: / Emergency Phone#:
Major:
Faculty Sponsor: / Faculty email:
Placement Site/Employer:
Placement Address:
On-site Supervisor: / Supervisor’s phone#:
Title: / Supervisor’s email:
Semester’s work start date:
Semester’s work end date:
Estimated hours per week or semester at site:
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. 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.
Date
Student Signature:
Instructor 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.
Check if completed (leave blank if unknown):Affiliation Agreement on file: / NH DOL form completed.
Return form to your instructor. For questions contact:
Karen Balnis
Service Learning and Internship Coordinator
Center for Engagement, Learning and Teaching
Cheshire House, 67 Winchester Street
Keene State College
229 Main Street, MS 3535
Keene, NH 03435
603-358-2916
Fax 603-358-2363
Keene State College Special Permission Form for Experiential Education Placements - Learning Agreement Page 3 of 5
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 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) Parent’s Signature (if releasor is a minor)
Print Name Print Name
Date
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 Date
______
Student Name - Printed
Keene State College Liability Release and Travel Waiver page 4of 5