Service-Learning Program
Bloomington High School North
uApplication must be turned in to room 513 by Friday, May 18.u
¨ Internship ¨ Cadet Teaching ¨ Community Service —NP ¨Community Service—Schools
Print Clearly STUDENT NAME: ______
SIGN NAME: ______YR OF GRADUATION:_____
ADDRESS: ______
CITY, STATE, ZIP: ______
PHONE: ______EMAIL: ______
PARENT/GUARDIAN SIGNATURE: ______
You must have a car to get you to and from your site everyday or every other day. The city bus does not pick up students on times that match our schedule and you are not allowed to carpool with other students unless they are a sibling of yours. Please answer the following questions with clear, legible handwriting. If additional room is needed attach additional comments. Please read everything in this application.
What are your future career plans in terms of a profession?
Why do you want to participate in the BHSN Service-Learning Program?
Please list five career areas that you hope to be placed in for service learning next year. Be specific.
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5.
Please list any specific business, organization, or school that you would really like to intern with and explain why (rank them in the order you would like). Be as specific as you can. Please exclude any organization where you have relatives working because you are not allowed to be placed with family. If you have names and contact information, please include it.
The BHSN Service Learning Program gives each student an opportunity to “intern” out in the community. Grading for this course is based on site evaluations from your site supervisor as well as assignments each grading period. 1st semester each student will create a portfolio. There are three main phases of this portfolio, due the week before the end of each 6 weeks grading period. Students will also create a resume, cover letter, and complete 4-6 Canvas assignments per grading period. Seniors focus on Senior Project during 2nd semester, which involves a formal research paper and a 10-15 presentation on Senior Project Night. Juniors must attend Senior Project Night and participate as room facilitators. This program requires more accountability and responsibility than most BHSN courses because you are out in the community. As a result, students can be removed from this program if they create problems at their site or they skip. Also, during the first two weeks of school students don’t go to their site, but rather stay at BHSN.
We have a large number of students that have enrolled in our SL programs and we offer these programs throughout the day. Below is when you can take the classes in the BHSN Service Learning Program. If you are wanting to be placed in a school (especially an elementary school), you must have your class in the afternoon. You will need to get with your counselor and make sure that you get the block of time you are hoping for.
• Comm. Service—Non-Profit (11-12 graders) 0524-0E (1 credit class, can be taken M1, G5, M4 or G8).
• Comm. Service—Schools (11-12 graders) 0524-0S (1 credit class, can be taken M1, G5, M4 or G8).
• Cadet Teaching (12 graders) 0502-0E (2 credit class, can be taken M1&M2, G5&G6, M1&G5 M3&M4, G7&G8, or
M4&G8). If you want to cadet teach in a middle school, you can take this class in the morning. If you want to cadet in an elementary school, you must take this class in the afternoon.
• Senior Internship (12 graders) 0530-0E (2 credit class, can be taken M1&M2, G5& G6, M1&G5, M3&M4, G7&G8, or
M4&G8). Understand that if you take this in the morning, there are fewer businesses open at 8:00 am. For those students who take this class in the morning, you go straight to your site. You don’t come to BHSN first.
SERVICE-LEARNING PROGRAM
Bloomington High School North
Parent Permission Form – (Please Print)
With your permission, we have enrolled ______in the Student Career Internship program during the ______school year. An internship is a work-based learning experience in a field related to a student’s academic and career objectives. It is considered an extension of the regular school program and the student receives credits and grades for their experience. Work-based activities at participating organizations may include special projects, a variety of tasks related to different positions in a career filed, or tasks performed in a single position within a career field.
This program requires that your son/daughter provide his/her own transportation to the training site. If you permit your child to drive to this training site; the school assumes no obligation for accidents or injury during travel related to this program.
Also, students in an unpaid internship program are not employees; therefore, Workman’s Compensation insurance may not apply. Therefore, the training site may not be responsible for accidents or injury that may occur at the training site. In order to insure your son/daughter’s safety we would like to be assured that you son/daughter has medical insurance.
Permission to Participate as a Student Intern
______may participate in a student internship as specified in the internship agreement, which will be completed once the student is officially placed with an organization as an intern.
Permission to Travel to Intern Site
I grant permission for my son/daughter to travel using his/her own car.
YES NO (Please Circle One)
Name of Automobile Insurance Company: ______
Policy Number: ______Agent Name: ______
Photo Release
I grant permission for my son/daughter to be photographed, videotaped, or film the student (including student’s name) in conjunction with any activity or function associated with the Student Career Internship program. I hereby give permission for the school district, Franklin Initiative, Region 10 School to Career, their affiliates and/or assigns to use the same in any promotional, marketing, publicity or advertising materials, or in any other manner whatsoever, without consent of, or payment of any compensation to the student or any other individual or individuals involved.
YES NO (Please Circle One)
Medical Authorization and Insurance Information
I understand and accept that the business community can be hazardous environment with risks and that injuries are a potential occurrence of industry. As a condition of my student being permitted to participate in a school sponsored internship, I freely accept and voluntarily assume the risks of injury and release the internship site, its employees and agents, the school corporation, and Franklin Initiative, from any and all liability for personal injury resulting from negligence, conditions of the premises, operations of the business entity, actions or omissions of employees or agents of the above, or from participation in the internship, accepting myself the full responsibility, including financial, for any and all such injury of any kind which may result.
Should it be necessary for my son/daughter to have medical treatment while participating as a student intern, I hereby give the school district and/ or intern site personnel permission to use their best judgment in obtaining medical service for my child, and I give permission to the physician selected to render whatever medical treatment he/she deems necessary and appropriate.
YES NO (Please Circle One)
Permission is also granted to release emergency contact/ medical history to the attending physician or to the intern site personnel, if needed.
YES NO (Please Circle One)
Health Insurance Company: ______
Name of Policy Holder: ______
Identification Number: ______Account Number: ______
Family Doctor Name: ______Phone: ______
Daytime Parent/ Guardian/ Other Contact Name: ______
Daytime Phone for Parent/ Guardian/ Other Contact: ______
______
Parent/ Guardian Signature Date