Co-op Application Form
CO-OPERATIVE EDUCATION and Other Forms of Experiential Learning
APPLICATION FORM
Year applying to Co-op: 1
st
Semester 200___ or 2
nd
Semester 200___
PERSONAL INFORMATION
Student’s Name (Last, First)
M / F Age Language(s) (Other than English)
Address _________________________________________________________________________
________________________________________________________________________________
Postal Code __________ Telephone No.________________ Cell Phone No. __________________
E-mail Address: __________________________________________________
Birthdate (Day-Month-Year)__________________
CONTACT INFORMATION
Parent/Guardian Name ______________________ ____________________ ___________________
Home No.________________ Business No. _________ _______Cell Phone No . ________________
Parent/Guardian Name ______________________ _________________________ _______________
Home No.________________ Business No. ________________Cell Phone No. ________________
Emergency Contact ___________________________ __________________________ __________
Home No.________________ Business No. _________ _______Cell Phone No . ________________
Doctor’s Name_____
_____________________ Busi ness No. ___________
List any relevant medical probl ems: _______________________ _______________ _______________
WORK EXPERIENCE
Paid/ Volunteer Work Experience/Extracurricular Activities
Name of Company/Organization Position Dates
________________________________ ____________ ____________________
________________________________ ____________ ____________________
________________________________ ____________ ____________________
EDUCATION
List any previous courses that you have taken which are related to your placement selection.
(Grade/Level/Course Code)
1. ____________________________________ 2. ___________________________________
3. ____________________________________ 4. ___________________________________
List any relevant skills, interests, certificates, hobbies, etc.
______________________________________________________________________________
What are your plans after Graduation?
Work ________ College ________ University _________ Apprenticeship _________
SELECTION
Co-op Preferred: Semester 1 _____ Semester 2 _____ 2 credit _____ 3 credit _____ 4 credit _____
Cooperative Education: __________ OYAP: __________
Specialist High Skills Major: __________________________________
Type of work placement requested: First Choice _______________________________________
Second Choice _____________________________________
APPROVAL
Parents/Guardians must recognize that each student:
• Will be interviewed by the Cooperative Education teacher to determine suitability for the program.
• Is to attend both in-school classes and the placement as scheduled.
• Is to report any absence to both the Coop teacher and the Placement Supervisor.
• Is covered under the Workplace Safety Insurance Board by the Ministry of Education, or is covered by the School
Board’s Insurance policy.
• Will only receive credits after all in-school assignments and placement hours are successfully completed.
Freedom of Information Act – In accordance with the Freedom of Information and Privacy Act, effective January 1991 this information is being requested with the consent of the applicant and his/her legal guardian if under the age of eighteen.
Signature of the student and guardian will assume consent to the issuance of this information as part of the cooperative education program. Also, permission is granted to use photos taken at the Coop placement in any board literature.
_______________________________________ _________________________
Student Signature Date
_______________________________________ __________________________
Parent/Guardian Signature Date
