☐ Apprenticeship Work-Based Learning Business Procedure Intern
☐ Coop Parent/Guardian Consent Form
☐ Internship STUDENT INFORMATION
Name: Click here to enter text. / Home Phone: Click here to enter text.Address: Click here to enter text. / Parent Cell Phone: Click here to enter text.
City: Click here to enter text. Zip Code: Click here to enter text. / Student Cell Phone: Click here to enter text.
E-Mail: Click here to enter text. / Student I.D. Number: Click here to enter text.
High School: Click here to enter text. / ☐ Male ☐ Female
Mother/Legal Guardian Name: Click here to enter text. / Daytime Telephone: Click here to enter text.
Father/Legal Guardian Name: Click here to enter text. / Daytime Telephone: Click here to enter text.
Please print this form, initial/complete each request, and sign below to indicate your consent.
______Work-Based Learning Assignment Consent: I understand that my child named above is enrolled in the work-based learning program at the school listed above and will be assigned to an office/department in the local school as an intern.
______Confidentiality: I understand that my son/daughter is bound to the adherence of the confidentiality clause in the Training Agreement signed by the student, the parent and the student’s supervisor/mentor as part of the Work-Based Learning Program. Depending on the Student’s job assignment within the school, the student may be exposed to confidential information about another student, teacher, administrator or situation. Confidentiality in these matters is imperative. Breach of confidentiality could result in removal from the Work-Based Learning Program.
______On-Campus Only: I understand that Business Procedure Interns do not leave campus to perform the duties of their job assignment. Students are required to remain on campus and under the direct supervision of their on-site supervisor/mentor. Students will not be allowed to loiter, use electronic devices that are not used as part of their job, or conduct any activities that are not connected to their job responsibilities.
______Field Trip/Class Projects: Permission is granted for my son/daughter/ward to participate in field trips and class projects during the session(s) he/she attends Gwinnett County Public Schools. Transportation may be provided by the school system. In addition, another form requiring signature may be required by the local school designating the destination and purpose of the field trip along with the departure and return date information.
______Photo/Media Release: I hereby give my consent to all photographs, audio recordings, and/or video recordings taken of me or my minor child by Gwinnett County Public Schools or their designee. I understand that any photographs, audio recordings, and/or video recordings become the property of the local school/district/designee and may be used by the school, district, or others with the consent, for educational, instructional, or promotional purposes determined by the district in broadcast and media formats now existing or to be created in the future.
______Student Record Release: I authorize the Gwinnett County Public School System to release my son/daughter/ward’s academic and attendance records to the Work-Based Learning Coordinator for the purpose of evaluation for suitability to participate in this program. I agree that the Gwinnett County Public Schools and its agents will be absolved of any responsibility in connection with such release. This authorization can be cancelled at any time by written notice to the Work-Based Learning Coordinator.
Health/Medical:
______Treatment Consent: I hereby authorize the school or the work-based learning coordinator or work-site mentor to secure emergency medical treatment. I will assume all financial responsibility.
______Insurance: Health Insurance Company ______Student is or is not ______covered by medical insurance. (If not, parent/guardian signature indicates that accident insurance will be purchased through the school insurance program. Contact your local school.)
HAVING READ WITH UNDERSTANDING THE ABOVE, I HEREBY GIVE MY CONSENT TO THE ENROLLMENT OF MY SON/DAUGHTER/WARD IN A WORK-BASED LEARNING PROGRAM:
PARENT/GUARDIAN SIGNATURE ______DATE ______
Student’s Signature ______DATE______