Cooperative Education Application
Coop
It’s Working!
100 Main Street West
Hamilton, Ontario L8P 1H6
905-527-5092
STUDENT INFORMATION
TYPE OF PLACEMENT REQUIRED
NAME:_____________________________________
1ST CHOICE:__________________________
ADDRESS:__________________________________
2ND CHOICE:_________________________
____________________________________________
3RD CHOICE:_________________________
POSTAL CODE:__________ PHONE:____________
PREFERRED TIME AND SEMESTER
E-MAIL: ___________________________________
PRESENT GRADE:___________________________
SEMESTER 1
AM
□
PM
□
BIRTH DATE:_________________ AGE:_________
SEMESTER 2
AM
□
PM
□
TOTAL CREDITS TO DATE:__________________
SELF-ASSESSMENT
Please indicate if you:
□ bus pass □ driver's licence □ daily use of a car
speak another language: □ yes □ no
If yes, please specify __________________
1a) have any of the following:
1b)
1c) have computer skills: list program(s) __________________________________________
2. Total days absent last semester: ___________ Total days late last semester: _________
3. State two teachers we can approach to recommend you for Co-op.
a) ___________________________________ b) _____________________________________
4. What is your Post-Secondary Education/Career Choice?
□
□
□
□
Work
Apprenticeship
University
Community College
5. What is your long-term career goal? ____________________________________________
*NOTE:
IF YOU HAVE ALREADY SUBMITTED AN OPTION SHEET, PLEASE HAVE YOUR GUIDANCE
COUNSELLOR REMOVE THE FOLLOWING 2 COURSES SELECTED: ________________& _________________
CONDITIONS OF PARTICIPATION
All Co-operative Education students are under the supervison of the Principal & the Co-op teacher. There will
be no wage or salary paid to the student. The student must be successfully interviewed by the Co-op teacher
& an employer. The student must complete the pre-placement orientation assignments prior to the start of
placement. The student must attend both the in-school classes and Co-op placement as scheduled. The
student must report any absences to both the Co-op teacher and the training supervisor. Hours missed at the
placement, will be made up at a time mutually convenient to both the student & the employer. Students are
expected to be punctual at all times. Chronic lateness or absenteeism on the job or at in-school sessions will
not be tolerated and may result in dismissal from the Co-op program.
Workplace Safety Insurance Board (WSIB)
All students participating in the Board’s Cooperative Education Program are covered by either Workplace Safety Insurance Board
and/or student accident and liability insurance as follows:
1.
Under the Workplace Safety Insurance Act, Cooperative Education students are “deemed” to be employees of the Ministry of
Education for coverage, although wages are not paid.
2.
The Workplace Safety Insurance Act provides compensation, medical aid, rehabilitation services, and pensions for employees
injured in on-the-job accidents.
3.
Students will be covered by Workplace Safety Insurance during the time they spend at the training station under the
supervision of the training organization. Students are not covered for classroom or shop work in the school when working as
teacher’s aides or when traveling to or from the training station.
4.
Student accident insurance coverage is extended to students, at no cost to either the board or the parents, through the Reliable
Life Insurance Company. Coverage includes travel directly to and from the program and the home or the school.
5.
In the event of injury or accident, it is the responsibility of the student/parent/guardian to notify their Coop teacher
immediately.
RESTRICTIONS
1. Some Coop placements require that students be bonded. Is there any reason why you would not be bondable?
2. Are there conditions or restrictions that may prevent you from participating in the program? (i.e.: trespassing,
shoplifting, violation of terms of probation, court order, etc.)
3. Are there any charges or investigations pending that may affect or restrict your placement in this program?
4. Car Insurance: If the placement I accept requires me to use my personal or family’s car, I hereby agree that my
own car insurance must cover me in case of an accident. I have notified my insurance company of the use of
the vehicle for my Coop placement.
5. Release of Information: in determining an appropriate Cooperative Education placement, I hereby agree to
the release of information that employers may request regarding attendance, reliability, work habits or any other
information relevant to my work placement.
Yes
No
Yes
Yes
No
No
Yes
No
Yes
No
CONSENT
In accordance with section 29(2) of the Municipal Freedom of Information and Protection of Individual Privacy Act, please be advised that the
personal information obtained in this application form is collected under the authority of the Education Act as amended and will be used to assess
your eligibility for inclusion in an appropriate Co-operative Education Placement. Questions regarding the collection of this information may be
directed to the Director of Education: 100 Main Street West, Hamilton, ON L8N 3L1 at 905-527-5092
"I HAVE READ AND UNDERSTOOD ALL OF THE CONDITIONS AND HEREBY AGREE TO THE PARTICIPATION
OF MY SON/DAUGHTER/WARD IN THE CO-OPERATIVE EDUCATION PROGRAM OF THE HAMILTONWENTWORTH DISTRICT SCHOOL BOARD."
Student Signature:____________________________________________________________________ Date:_________________
Parent/Guardian Signature:_____________________________________________________________ Date:_________________