SCHOOL DISTRICT OF BENSALEM TOWNSHIP
BENSALEM SENIOR HIGH SCHOOL
4319 HULMEVILLE ROAD, BENSALEM, PA 19020
(215) 750-2800 Ext. 3097
APPLICATION FOR ENTRANCE
COOPERATIVE EDUCATION PROGRAM
Date_____________
Name___________________________________________________ PA Secure ID__________________
Home Address__________________________________________________________________________
________________________________________________________Phone Number__________________
(City)
(State)
(Zip)
Date of Birth_____________________Age Last Birthday____________Present Grade________________
Name of Parents or Guardians______________________________ _______________________________
Name of Mother’s Employer________________________________
Phone Number___________________
Address of Mother’s Employer______________________________________________________________
Name of Father’s Employer________________________________
Phone Number___________________
Address of Father’s Employer______________________________________________________________
POLICY Relative to Student Illness and First Aid
In the case of illness we contact the parents or the designee and they are responsible for seeing that the
child is taken home. In the event of an accident, emergency first aid is rendered. If the accident is
serious enough to require further care we will contact the parents of the student who are responsible for
making the necessary arrangements for such care. In an extreme emergency the injured party will be
transported to the nearest hospital by the local rescue squad and the parents will be notified to go to the
hospital.
Name of Family Doctor____________________________________________________________________
Address__________________________________________Phone No.______________________________
Name of Hospital Preferred________________________________________________________________
Name of someone who is designated to assume responsibility for the care of my child if the school is unable
to reach the parents:
Name________________________________________________________________
Address______________________________________________________________
Phone Number_________________________________________________________
BENSALEM HIGH SCHOOL
COOPERATIVE EDUCATION PROGRAM
ENTRANCE INFORMATION
Who May Participate
A student who:




is 16 years or older
is in the 12th grade
is in good academic standing
has an acceptable discipline record
How The Student Enters The Cooperative Education Program
The student will:
* complete an application
 include the parent’s signature
 apply for “working papers”
The parent will:
*


give the student permission to work
furnish auto insurance information
indicate the type of transportation the student may use to go to
work
Transportation Information
The student must obtain an approved method of transporation.
My daughter/son has permission to use the following means of
transportation to go to work.
(Please check those that
are applicable)
___
___
___
___
___
___
___
___
car
bicycle
motorcycle
ride with another student
drive with parent
ride with a non-student
drive with passengers
walk
_______________ ____________ _________________________________ ______________
Make of Car
Color
License Number
Year
_____________________________________________
Name of Auto Insurance Company
________________________________
Amount of Liability Coverage
The field representative will:


*


interview the student
review the student’s academic record
review the student’s discipline record
provide interviews for a possible placement at a training station.
Determine if a potential training station will provide an adequate
learning experience
When The Student Is In The Cooperative Education Program
Credit
*
Credit toward graduation is received quarterly on the report card
Marks
*
The employer and the field representative will determine a mark for
the student. School attendance and tardiness are a part of the
Grade.
Discipline
*
A student may be removed from the program if he or she is in
Violation of school or program regulations.
______________________________________
Student’s Signature
Date
______________________________________
Field Representative Signature
_______________________________________
Parent’s Signature
Date
_______________________________________
Principal’s Signature
Date
BENSALEM HIGH SCHOOL
COOPERATIVE EDUCATION PROGRAM
POLICY ON TARDINESS AND ABSENTEEISM
1.
2.
3.
4.
5.
6.
7.
Students must be to school on time. It is important that the student be in homeroom by
7:10 A.M.
Tardiness will be calculated on the basis of minutes late. When a student has accumulated a
total of 100 minutes late to school he or she may be removed from the program.
If a student is not in school he or she may not attend work. The assistant principal in the
student’s program area is the only person who can make an exception to this rule.
When a doctor’s appointment is scheduled, the student must come to school first to obtain an
early dismissal or arrive at school, with a doctor’s note, after the appointment.
Suspended students, in school or out, are not permitted to work on the day(s) of suspension.
Suspension may be a cause for removal from the program.
Each student must “clock out” every day when leaving school.
I fully understand this policy and agree to abide by the policy for tardiness and absenteeism.
____________________________________ __________
Student’s Signature
Date