WBL Application

Work-Based Learning Application
Full Name

First NameMiddle NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address
Phone Number

Area CodePhone Number
When will you be completing your WBL course?
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Previous Work Experience

Please provide details about work experience that is applicable to your WBL placement preference
Business/Organization Name
Primary Contact Name
Promary Contact Email
Position
Street Address (Line 1)
Street Address (Line 2)
City
State
Zip Code
Phone Number

Insurance Agreement

I understand that I have been accepted for a Work-Based Learning work assignment.

I acknowledge that the college will assume no financial responsibility in the event of any accident or illness suffered by me, the student, as a result of the student's work activities while enrolled in a Work-Based Learning course at Haywood Community College. I also understand that I am personally responsible for seeing that arrangements are made through personal insurance or private funds to cover costs incurred for medical, surgical or emergency treatment of any accident or illness suffered while involved in the work-based learning partnership between the college and the employer. In the case of paid, for-credit work experiences, Workman's Compensation will apply. For unpaid, for-credit work experiences, Student Accident Insurance will serve as a secondary accident policy in some cases. See attached document for more information regarding the Student Accident Insurance policy.

By entering your initials into this box, you agree:
I have read and agree to the Student Accident Insurance Policy Coverage. I understand that routine medical care will not be covered by the Student Accident Insurance Policy and that it is my responsibility to seek personal medical insurance coverage or go without.
Enter Initials Here*

Confidentiality Agreement

I understand that:

Information that I have access to or learn through my work-based learning employment may be confidential, and cannot be shared with any other person or employer, regardless of intent. Confidential information may include, but not be limited to:

-Blueprints and drawings of facility

-Product specifications and information

-Client information

-Company personnel information

-Patient medical records

-Photos of workspace, computer screen, files, confidential documentation, patients or employees. Photos and videos taken at the work site will be done so only with the permission of the work site supervisor, and will NOT be uploaded to the internet, including social networking sites or emails.

I must comply with the policies and procedures outlined by my employer

I will not access, use or disclose of any confidential information that I learn or possess during my affiliation with my work site/ employer unless it is necessary for me to do so in order to perform my job responsibilities, or if required by law. I understand that under no circumstances may confidential information be communicated either within or outside of my work site except to other persons who are authorized by my work site to receive such information.

I will not alter, destroy, copy or interfere with confidential information unless I am authorized by my work site supervisor.

I will keep computer access codes confidential and secure. I will protect physical access devices and the confidentiality of any information from being accessed by unauthorized persons.

I accept responsibility to keep my access codes and ID cards private and confidential, and will not attempt to use those of others unless instructed by my supervisor. I understand that it is my responsibility to report compromised, lost or stolen access codes or ID cards to my direct supervisor immediately.

I understand that failure to comply may result in termination of my employment or affiliation with my work site and/or failing grade in co-op course and/or potentially legal action.

By entering your initials into this box, you agree that:
I have read and agree to the Confidentiality Agreement.
Enter Initials Here*

Acknowledgement of Expectations

As a WBL student, you are required to complete a minimum of 160 hours during your WBL semester. In order to receive a grade of P (pass) in this course, you must also submit all required forms and documents. For MOA and HBI students, these forms include:

-Application -North Carolina Student Medical Forms

-9 Panel Drug Screening

-Criminal Background Check

-3 Measurable Learning Objectives

-End of Term Evaluation

-Weekly Time Records

For students in programs other than MOA or HBI, you will be required to complete all forms listed above, with the exception of the Student Medical Form, 9 Panel Drug Screening and Criminal Background Check, although some work sites may require background check and/or drug screening. This requirement will be assessed based on your work site placement.

By entering your initials into this box, you agree that:
I have read and agree to the expectations listed above in order to receive a passing grade in my WBL course.
Enter Initials Here*
By typing your name into the box below, you agree that the information typed into this form is accurate and honest.
Name (First & Last)*
Student ID Number*
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Work-Based Learning Application