8364 Shawnee College Rd.

, Ullin, IL 62992

WORK-BASED LEARNING PROGRAM AGREEMENT

Students Name_____________________________ School_______________________
Date: _________________ Age: __________ Social Security #:____________________
Work/ Business Name: ____________________________________________________
Business Address: ________________________________________________________
Business Phone: ____________________Work Supervisor: _______________________
Student Hours: ___________________________________________________________
Responsibilities of the Student Learner
1. The student will keep regular attendance, both in school and on the job, and
cannot work on any school day he/she fails to attend school; he/she will notify the
school and employer if unable to report.
2. The students participation in the program will be terminated if he/she does not
remain in school.
3. The student will show honesty, punctuality, courtesy, a cooperative attitude,
proper health and grooming habits, good dress, and a willingness to learn.
4. The student will consult the teacher-coordinator about any difficulties arising at
the work place.
5. The student will conform to the rules and regulations of the workplace.
6. The student will furnish the teacher-coordinator with necessary information and
complete all necessary reports.
Responsibilities of the Supervisor
1. The supervisor will consult the teacher-coordinator about any difficulties arising
at the training station.
2. The supervisor will assist in evaluating the student.
3. The supervisor will provide time for consultation with the teacher-coordinator
concerning the student.
4. The supervisor will provide instructional material and occupational guidance for
the student as needed and available.

Revised: 8/5/2009
Learning.doc

Work Based

Responsibilities of the Teacher-Coordinator

1. The teacher-coordinator will coordinate related classroom instruction and on-thejob training to improve job performance and to better prepare the student for the
world of work.
2. The teacher-coordinator will see that necessary related classroom instruction is
provided.
3. The teacher-coordinator will make periodic visits as necessary to the training
station to observe the student and consult with the supervisor.
4. The teacher-coordinator will consult with the supervisor.

This agreement may be terminated by mutual consent of the supervisor and

the teacher-coordinator.

It is understood that the parties participating in this agreement will not discriminate in
opportunities on the basis of race, religion, color, sex, or national origin.

_______________________________________________________________________
Student
Date

________________________________________________________________________
Work-Based Learning Supervisor
Date

________________________________________________________________________
Teacher-Coordinator
Date

8364 Shawnee College Rd. Ullin, IL 62992 618.634.3200 Fax: 618.634.3300

Revised: 8/5/2009
Learning.doc

Work Based