PRACTICUM
Agreement
Student Name:_____________________
High School:__________________
Home Phone:_______________________
School Phone:_________________
Name of Faculty Practicum Advisor:___________________________________
Practicum Worksite:______________________________________________
Address:_______________________________________________________
Practicum Supervisor:__________________ Supervisor's Title:____________
Supervisor's Phone:____________________ Supervisor's E-Mail:___________
Title of Practicum Position:_________________________________________
Term of Practicum:
_____Fall______Winter _____Spring _____Summer
Practicum Work Schedule:_________________________________________
Practicum Start Date:__________________
Agreement
This contract may be terminated or amended by the student, faculty practicum advisor, or employer at
any time upon written notice to the Program Coordinator. If, for any reason, the Practicum is
terminated prior to the official ending date, the student will not receive any credit. The student must
work a total of 45 hours between the dates set forth for that semester/term. Attendance at each of
scheduled Career Development meetings is mandatory. You must complete the entire 45-hour program
and attend the assigned meetings. Failure to attend these meetings, complete the guided journal or
complete the 45 hours may cancel your participation in this program, forfeit your credit and disqualify
you from future participation.
Student Signature:__________________________
Date:_______________
Parent/Guardian Signature:____________________
Date:_______________
Worksite Supervisor Signature:_________________
Date:_______________
H.S. Representative Signature:__________________
Date:_______________
-Over-
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Practicum Site Policy Adherence Agreement
for Student Program Participants
I, the undersigned, acknowledge that I will abide by the regulations and policies of my
practicum site host with respect to confidentiality at the worksite, computer and equipment
usage and all other regulations and policies set forth by my workplace. I agree to participate in
the Workplace Learning Connection Student Practicum Program under the conditions set forth
by the Workplace Learning Connection, my high school and my internship site host.
________________________
Student Name Printed
________________________
___________________
Signature
Date Signed
Learning Goals for my practicum ( Use the SMART model-specific, measurable, attainable,
realistic and timely-please list a minimum of two learning goals for your internship):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
____________________________________
This document will become part of the student's permanent high school
career development file when the Internship has been completed.
Please make sure all signatures are completed.
Please return this form to the address printed below.
Thank you!
Workplace Learning Connection
Linn Regional Center
1770 Boyson Rd
Hiawatha, IA 52233
(319) 398-1040
Workplace Learning Connection
1810 Lower Muscatine Rd.
Iowa City, IA 52240
(319) 887-3970
Workplace Learning Connection Student Internship Program provides equal opportunity to all persons regardless of
age, race, creed, color, sex, national origin, or handicap.
The Mission of The Workplace Learning Connection is to develop our future workforce by connecting business and education in
relevant, work-based learning activities for K-12 students and teachers in Area 10.
Additional career information is available at: www.workplace-learning.org
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