LEARNING AGREEMENT
Cooperative Education * Career Services * Central Washington University
400 E. University Way * Bouillon Hall 206 * MS 7499 * Ellensburg, WA 98926-7499
509-963-2405 * fax 509-963-1811 * www.cwu.edu/career
This agreement must be completed and approved by ALL signatories before registration can be completed.
Additional requirements and instructions pertaining to this Agreement are in the Student Workbook. It is the
student’s responsibility to know the requirements. Academic departments may have additional requirements.
(Revised 11-2014)
Office Use Only: Registration Date _________ Course _____________________ Course # ___________
Must be typed
STUDENT INFORMATION
Name: (First, Middle I., Last)
CWU I.D. Number:
Major:
Work Phone:
Evening Phone:
Cell Phone:
Mailing Address during Internship:
City:
State:
Country*:
Cumulative Credits:
Zip:
CWU email:
(Must have 45 credits to be eligible for 290; 90 credits for 490; grad student for 590 or 690)
Current Cumulative GPA:
Class Standing: Fresh
Quarter to Be Registered:
20
Soph
Jr
Sr
Post Bac
Grad
Expected Graduating Qtr/Yr:
Have you signed the Student Cooperative Education/Internship Release Form? Yes
Have you completed the Sexual Harassment Training? Yes
https://cwu.adobeconnect.com/_a787149012/p1znfe5ex92/)
Are you an International Student with a F1 visa? Yes
No
No
Date
Attach Certificate of Completion to this form.
No
International students on a F1 visa must obtain the signature of the International Student Advisor
*Please take this completed agreement to Study Abroad & Exchange Programs located in room 101 in the International Center if the
experience will take place outside of the United States. Additional paperwork will be required.
PLACEMENT INFORMATION
Employing Agency:
Web URL:
Internship Position Title:
Business or Agency Type / Industry: Non-Profit
For Profit
Government
Education
Employer Mailing Address: (POB or Street)
City:
State:
Zip:
Country:
Placement Address if Different:
Employer Supervisor:
Phone:
Title:
Cell Phone:
Work Hrs Per Week:
Paid ___Unpaid
CWU Alumnus/a Yes
email:
Academic Hrs Per Week
Wage Per Hr:
Starting Date: (mo/day/yr)
No
_Number of Weeks:
Other Compensation: (stipend, meals, lodging, mileage)
Completion Date (mo/day/yr)
EMERGENCY CONTACT INFORMATION
Name:
Relationship to Intern:
Emergency Contact Address:
Day Phone:
Total Hrs:
Evening Phone:
City:
State:
Cell Phone:
Zip:
email:
Academic Learning Plan - FACULTY INSTRUCTOR REQUIREMENTS
Course Prefix:
Faculty Instructor:
Course Number:
Number of Credits:
Campus Loc
Department / Office Phone:
Faculty Instructor Email Address:
Department Fax Number:
Academic Requirements to Be Completed: ( Choose Weekly, Bi-Weekly, monthly, bi-monthly,mid quarter, end of quarter)
Term Paper / Project Due:
Progress Reports Due:
Assigned Reading:
Other:
Journal or Log Due:
Final Report Due:
Number of Email Contacts:
Estimated hours per week outside the internship to meet academic requirements:
Faculty advisor or designee expects to contact student during placement as follows:
# of job-site visits
# of on-campus conferences
# of telephone conferences
INTERNSHIP DESCRIPTION:
LEARNING OBJECTIVES & ACTIVITIES: (Describe what objectives you and your advisor want you to be able to learn by the end
of the placement; then list what reading, writing, and on-the-job activities you will do to accomplish each objective. (Minimum of three
objectives and activities.)
EXAMPLE of Good Objective – To obtain a better understanding of administrative processes at camp and how the
organization is run.
EXAMPLE of Good Activities – Sit in on staff meetings as a division leader.
Help obtain and record info on campers progress in daily & weekly reports.
Attend training sessions during the week prior to camp starting.
Objective –
Activities –
Objective –
Activities –
Objective –
Activities –
Responsibilities of the Student
1. Maintain regular attendance at the site, notifying the site supervisor of anticipated absences
2. Abide by all state, federal, internship site and university rules and regulations
3. Inform immediately the work site supervisor and faculty advisor of any problems, concerns, and accidents/injuries.
4. Perform work in a timely and satisfactory manner.
5. Fulfill obligations of the Learning Agreement (including academic requirements and learning objectives) and training site preinternship requirements.
6. Complete the required Sexual Harassment Training provided by HR.
Responsibilities of the University
1. Encourage the student’s productive contribution to the overall mission of the Program site.
2. Certify the student’s academic eligibility to participate in a Program.
3. Establish guidelines and standards for the conduct of students enrolled in its Program and to make these guidelines and standards available to the
Program site
4. Designate a faculty member who will serve as advisor to the student, assist in setting learning objectives, confer with the Program site personnel,
monitor the progress of the student intern, and evaluate the academic performance
5. Maintain communication with the Program site and clarify any University policies and procedures.
Responsibilities of the Cooperative Education/Internship Site (Program Site)
1. Encourage and support the learning aspect of the student’s Program.
2. Designate a professional staff person/employee to serve as an advisor/supervisor with responsibilities to help orient the student to the agency and its
culture, to assist in the development of learning objectives, to confer regularly with the student and his/her faculty advisor, and to monitor the
progress of the student.
3. Provide adequate supervision for the student and assign duties that are related to the student’s area of interest.
4. Provide a safe space for the intern to complete necessary work functions, and make available necessary equipment and supplies.
5. Agree not to displace regular workers with students functioning in the Program role.
6. Notify the Career Services Internship Coordinator or your Internship Advisor of any changes in the student’s work status, schedule or performance.
7. Allow the Internship Advisor or Internship Coordinator to conduct a pre-arranged phone conference or site visit to confer with the student and his/her
supervisor.
8. Provide the REQUIRED mid-term and final evaluations of the student’s performance. Links for these will be emailed.
9. Maintain general liability, professional liability, Workers Compensation coverage, as required by law and comply with Fair Labor Standards Act
guidelines when providing unpaid internships in the “for-profit” sector.
10. Not discriminate on the basis of race, color, creed, religion, national origin, sex, sexual orientation, age, marital status, disability or status as a
disabled veteran or Vietnam era veteran.
11. Regardless of direct or indirect services to clients, should the Program site have clients of vulnerable population pursuant to RCW 43.43.830-.845,
Program Site agrees to obtain written permission from the Student Intern to perform the required criminal background check. Should negative
information appear on the Students criminal report, Program site will be responsible for determining if placement will be allowed.
Insurance Coverage
Central Washington University does not have an obligation nor does it provide health, accident, or hospitalization insurance. Washington State
laws do not allow the University to extend any of its professional or general liability coverage to students to cover their personal actions or negligence
while performing work or volunteering at any Program site. Further, the use of a personal vehicle may be required by an intern for the benefit of the
organization with whom they perform in the Program. Central Washington University provides no insurance for a student to operate his/her personal
vehicle. Central Washington University has no liability for injury or property damage which may result from that use. The Cooperative Education Program
is for the intern’s personal gain and academic credits. Interns will not be entitled to any Labor and Industries or Unemployment Compensation benefits
during or after the completion of the University Program.
Hold Harmless Clause
The Program Site and use of any and all of its facilities shall be undertaken by the Student at their own sole risk, and that Central Washington
University shall not be liable for any claims, demands, injuries, damages, actions, or causes of actions, whatsoever by the Student or property arising out
of or connected with the Program or with the use of any and all services, or facilities associated with the Program site, whether or not sponsored by
Central Washington University.
Each party shall defend, indemnify and hold the other party, its officers, officials, employees and volunteers harmless from any and all claims,
injuries, damages, losses or suits including attorney fees, arising out of injuries and damages caused by each party’s own negligence.
SIGNATURE BLOCK
We, the undersigned, agree with the validity of the Learning Agreement as proposed. The Employer and the University agree to provide the
necessary advising, direction and supervision to ensure that the maximum educational benefit is achieved from the Student's field
experience. The Student agrees to abide by the guidelines as outlined in the Student Workbook. The Employer Supervisor will evaluate the
accomplishment of the Student's Learning Plan and work performance at the end of the grading period. The Faculty Advisor will evaluate the
field experience and will award credit for successful accomplishment of the academic requirements and the Learning Plan.
Student:
Date
Employer Supervisor:
Date
Department Faculty Instructor:
Date
Department Chair/Program Director:
Date
Dean/Associate Dean:
Date
IF NECESSARY: International Student Advisor:
Date ____________________
IF NECESSARY: Study Abroad & Exchange Programs:
Date ____________________
Career Services
Date
(For Office Use Only):
Central Washington University
Career Services
Student Cooperative Education/Internship Release Form
This is a release. Please read carefully.
Students must submit this completed form and the Learning Agreement form
to Career Services in order to be registered for academic credit.
I, ___________________________________________, ID # _____________________________ am a student at
(Student name - please print)
Central Washington University, and plan to undertake my Co-operative Education / Internship Program during
Fall_____ Winter _____ Spring _____ Summer _____ at the following location:
(Year)
(Year)
(Year)
(Year)
______________________________________________________________________________________________
(Name of Program Site)
(City/State/Country)
Central Washington University itself does not control the way in which learning sites are structured or operate. In
granting credit for this cooperative education / internship (herein called the Program), the University affirms that, to the
best of its knowledge, the experience is an appropriate curricular option for students in Central’s program of study and
worthy of university credit; however, it makes no other assurances, expressed or implied, about any travel and living
arrangements the student has made.
Central Washington University does not knowingly approve program opportunities which pose undue risks to their
participants. However, any program or travel carries with it potential hazards which are beyond the control of the
University, its Board of Trustees, officers, agents or employees.
INSURANCE COVERAGE
I understand that some internship sites may require that I have sufficient health, accident, and hospitalization insurance to
cover me during my Program. I further understand that I am responsible for the costs of such insurance and for any
expenses not covered by this insurance, and I recognize that Central Washington University does not have an obligation
nor do they provide me with such insurance. I also understand that Central Washington University recommends that I
have sufficient health, accident, and hospitalization insurance during my internship experience.
I assume full responsibility for any undisclosed physical or emotional problems that might impair my ability to complete
the experience, and I release Central Washington University from any liability for injury to myself or damage to or loss of
my possessions.
I understand that Washington State Laws do not allow the University to extend any of it professional or general liability
coverage to students, to cover their personal actions or negligence while performing work or volunteering at any Program
site. Therefore I accept full legal and financial responsibility for my actions while performing my Program
responsibilities, and understand that I am personally liable for any injury or damage which I may cause.
I understand that if I use my personal vehicle for the benefit of the organization with whom I perform my Program,
Central Washington University provides no insurance for me to operate a personal vehicle and also has no liability for
injury or property damage which may result from that use. I agree to rely solely on my personal vehicle insurance
coverage and on any insurance coverage provided by the Program site.
Career Services * Central Washington University * 400 E University Way * Ellensburg, WA 98926-7499
206 Bouillon Hall * 509-963-1921 * Fax 509-963-1811 * career@cwu.edu
I understand that because my Program is for personal gain and academic credits, I will not be entitled to any labor and
industries or unemployment compensation benefits during or after the completion of my Program from the University.
Further, I understand that Central Washington University assumes no liability for injury that I may suffer in the course of
my Program, and requires that I be responsible for ascertaining whether my Program site provides Workers Compensation
coverage for me.
PERSONAL CONDUCT
I understand that the responsibilities and circumstances of an off-campus Program may require a standard of professional
etiquette that may differ from that of Central Washington University. Therefore, I indicate my willingness to understand
and conform to the professional standards of the Program site. In addition, I am in full understanding that the designated
Program site has requirements which I must meet prior to starting at the Program site, and failure to provide such
documentation may result in immediate cancellation of my Program experience. I agree to provide all site-required
documentation to the Associate Director of Career Services prior to starting my Program. I also further understand that it
is important to the success of the present Program, and the continuance of future Programs, that interns observe standards
of conduct that would not compromise Central Washington University in the eyes of individuals and organizations with
which it has dealings. I acknowledge the responsibility of Central Washington University and its Associate Director of
Career Services and the Professor involved in the Program to set rules and interpret conduct for this purpose. I agree that
should Central Washington University and its Career Services Associate Director or the Professor of the Program decide
that I must be terminated from my Program because of conduct that might bring the Program into disrepute or the
Program site into jeopardy, that decision will be final and may result in the loss of academic credit.
GENERAL RELEASE
I hereby authorize Central Washington University to release a copy of my criminal history background check, excludedparty checks, proof of immunizations, CPR Certification Card, student transcript, and any other documents so required by
the Program site or organization in consideration of my placement in their program. I understand that any negative
information found on any materials required by the Program site prior to placement may affect my consideration for
placement with the Program site. Therefore, I agree to release the University, its officers, agents and employees from any
liability associated with my Program placement should any negative information by found and my placement denied by
the Program site. I understand that Central Washington University reserves the right to make cancellations, changes or
substitutions in cases of emergency or changed conditions or in the general interest of its Programs. It is further expressly
agreed that the Program site and use of any and all of its facilities shall be undertaken by me at my own sole risk, and that
Central Washington University shall not be liable for any and all claims, demands, injuries, damages, actions, or causes of
actions, whatsoever to me, by me, or property arising out of or connected with the Program and with the use of any and all
services, or facilities associated with the Program, whether or not sponsored by Central Washington University. I do
hereby release, discharge and covenant not to sue Central Washington University, its Board of Directors, officers, agents
or employees regarding any and all liability that may arise out of injury, harm, death, or property damage, resulting from
my participation in this Program.
Student Signature: ________________________________________ Date: _________________________________
Date of Birth: ________________________________________
Parent / Guardian Signature: _________________________________ Date: ________________________________
(If the student is under the age of 18 at the time this form is signed, parent/guardian signature is required.)
(revised 11/2014)
Career Services * Central Washington University * 400 E University Way * Ellensburg, WA 98926-7499
206 Bouillon Hall * 509-963-1921 * Fax 509-963-1811 * career@cwu.edu