HomeMy WebLinkAboutMEMORANDUM OF UNDERSTANDING BETWEEN THE BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA BY AND ON BEHALF OG AUGUSTA STATE UNIVERSITY AND AUGUSTA RICHMOND COUNTY GOVERNMENT MEMORANDUM OF UNDERSTANDING BETWEEN
THE BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA
BY AND ON BEHALF OF
Augusta State UniversitX
AND
Augusta-Richmond County Government
This is a Memorandum of Understanding on the part of Augusta-Richmond County
Government (hereinafter referred to respectively as the "Facility") and the Board of Regents
of the University System of Georgia by and on behalf of Augusta State University
(hereinafter referred to respectively as the "Institution"). The Facility and Institution shall
be hereinafter jointly referred to as the "parties."
A. PURPOSE:
i. The purpose of this Memorandum of Understanding is to guide and direct the parties
respecting their affiliation and working relationship, inclusive of anticipated future
arrangements and agreements in furtherance thereof, to provide high quality applied
learning experiences for the Institution's students.
z. Neither party intends for this Memorandum to alter in any way their respective legal
rights or their legal obligations to one another, to the students and faculty assigned to
the Facility, or to any third party. However, the understandings contained herein may
be incorporated into and made a part of a subsequent agreement executed between the
respective Institution and Facility in a form substantially similar to that which is
attached hereto and hereby incorporated by reference as "Exhibit A" (hereinafter
referred to as the "Agreement").
B. GENERAL UNDERSTANDING:
i. The applied learning experience (hereinafter referred to as the "A.L.E.") will be of
such content, and cover such periods of time as may from time to time be mutually
agreed upon by the Institution and the Facility. The starting and ending dates for each
A.L.E. shall be agreed upon at least one month before the A.L.E. commences. A.L.E.
implementation at the Facility shall be subject to final approval by the Facility.
z. The number of students designated for participation in the A.L.E. will be mutually
determined by agreement of the parties, and may at any time be altered by mutual
agreement. All student participants must be acceptable to both parties. Either the
Facility or the Institution may withdraw any student from an A.L.E. at the Facility
: based upon a lack of competency on the part of the student, the student's failure to
comply with the rules and policies of the Facility, or, for any other reason where
either party reasonably believes that it is not in their best interest for the student to
continue. Such party shall provide the other party and the student with immediate
notice of the withdrawal and written reasons for the withdrawaL
3. There shall be no discrimination on the basis of race, national origin, religion, creed,
sex, age, disability or veteran's status in either the selection of students for
participation in the A.L.E., or as to any aspect of the A.L.E.; provided however, that
with respect to disability, the disability must not be such as would, even with
reasonable accommodation, in and of itself, preclude the student's effective
participation in the A.L.E.
C. FACILITY RESPONSIBILITIES:
i. The Facility will retain responsibility for the care of its clients and patients and will
maintain supervision of students insofar as their presence and A.L.E. assignments
affect the operation of the Facility and its care, direct and indirect, of its clients and
patients. No provision of this Relationship shall prevent any Facility client or patient
from requesting not to be a teaching client or patient or prevent any member of the
Facility's staff from designating any client or patient as a non-teaching client or
patient.
z. The Facility will provide adequate facilities for participating students in accordance
with the A.L.E. program objectives and plan developed through cooperative planning
by the Institution's departmental faculty and the Facility's staff. The Facility will use
its best efforts to make conference space and classrooms available as may be necessary
for teaching and planning activities in connection with the A.L.E. However, specific
classroom, conference space and facility requirements may be set forth in the
Agreement.
3. Facility staff shall upon request, assist the Institution in the evaluation of the learning
and performance of participating students, provided the student has signed a consent
to exchange of educational information in accordance with the Family Educational
Rights and Privacy Act of i974, as amended. However, the Facility hereby agrees to
keep confidential any student records or information it may obtain, unless it has
otherwise obtained prior written consent of the student. Although the Institution
shall obtain all required consents, the Facility shall have the right to rely on such
consents and to obtain copies of such consents upon request. The Facility will assign a
staff representative as liaison between the Facility and the Institution. The Facility
staff representative may be designated in the Agreement. Unless otherwise specified
in the Agreement, any evaluation of students by the Facility shall relate only to
general student participation in the A.L.E., and shall in no way be construed as a
certification by the Facility as to the competence of any student or a representation by
the Facility of any student's ability or competence in connection with the practical
implementation of any knowledge gained through the A.L.E.
4. The Facility shall provide for the orientation of both Institution faculty and
participating students as to the philosophies, rules, regulations and policies of the
Facility.
5. Subject to the Facility's overall supervisory responsibility for patient care,
� appropriately licensed Institution faculty members may provide such patient services
at the Facility as may be necessary for teaching purposes. The nature and scope of
activities of Institution faculty members that may involve in any way patient care at
the Facility shall be subject to the sole discretion of the Facility and to such conditions
as the Facility may deem necessary in its sole discretion including, but not limited to,
prior proof of professional liability coverage, appropriate licensure or certification,
and compliance with all Facility rules, regulations, and policies. If faculty
participation at the Facility other than as a Supervisor for the purpose of this A.L.E. is
so authorized, it must not be a substitute for adequate staffing at the Facility.
6. All medical or health care (emergency or otherwise) that an Institution student or
faculty member receives at the Facility will be at the expense of the individual
� � involved. � � � �
D. INSTITUTION RESPONSIBILITIES:
i. The Institution will use its best efforts to select students for participation in the
A.L.E. who are prepared for effective participation in the training phase of their
overall education. The Institution will retain ultimate responsibility for the education
of its students.
z. Prior to the commencement of the A.L.E., the Institution wi11, upon request and with
proper authorization, provide responsible Facility officials with such student records
as will adequately disclose the prior education and related experiences of prospective
student participants. '
3. The Institution will use its best efforts to see that the A.L.E.s at the Facility are
conducted in such a manner as to enhance the resources available to the Facility for
the providing of care to its clients and patients. Only those students who have
satisfactorily completed the prerequisite courses of their curriculum will be selected
for participation in an A.L.E., as specified in the curriculum course descriptions.
4. The Institution will not assign any faculty member to the Facility in connection with
the operation of the A.L.E. who is not appropriately licensed or certified, and will
make evidence of the licensure or certification of all its assigned faculty available to
the Facility upon request. It is agreed that all Institution faculty are employees of the
Institution, unless otherwise agreed upon in writing.
5. The Institution will inform all its participating students of the Facility's requirement
that they must procure and maintain throughout the A.L.E. professional liability
insurance in amounts, form, and by a carrier satisfactory to the Facility and the
Institution, and covering their activities at the Facility, and to provide evidence of
such insurance to the Facility prior to participation in any A.L.E. Institution faculty
members will be provided professional liability coverage pursuant to the terms and
conditions of the Georgia Tort Claims Act (O.C.G.A. 050-zi-zo et seq.�. The
Institution will provide Worker's Compensation Insurance coverage for its
. participating faculty members. However, the Institution will not provide Worker's
Compensation Insurance or other insurance coverage for its students. This paragraph
will survive the termination of this MOU.
6. The Institution will encourage participating student and faculty compliance with the
Facility's rules, regulations and procedures, and use its best efforts to keep students
and faculty informed as to the same and any changes therein. Specifically, the
Institution will keep each participating student and faculty member apprised of his or
her responsibilities, including but not limited to the following:
a. To follow the administrative policies, standards and practices of the Facility
when in the Facility.
b. To report to the Facility on time and to follow all established regulations of
the Facility.
c. To keep in confidence all medical, health, financial and social (including
mental health) information pertaining to particular matters, clients or patients.
d. To not publish any material related to the A.L.E. that identifies or uses the
name of the Institution, the Board of Regents of the University System of
Georgia, the Facility or its members, clients, students, faculty or staff, directly
or indirectly, unless prior written permission is received from the Institution,
the Board of Regents of the University System of Georgia, and the Facility.
However, the Facility hereby grants to the Institution the right to publish
Institution administrative materials such as catalogs, course syllabi, A.L.E.
reports, etc. that identify or uses the name of the Facility or its members, staff,
directly or indirectly.
e. To comply with all federal, state and local laws regarding the use, possession,
manufacture or distribution of alcohol and controlled substances.
f. To follow Centers for Disease Control and Prevention (C.D.C.} Universal
Precautions for Bloodborne Pathogens, C.D.C. Guidelines for Tuberculosis
Infection Control, and Occupational Safety and Health Administration
(O.S.H.A.� Respiratory Protection Standard.
g. To arrange for and be solely responsible for living accommodations while at
the Facility.
h. To conform to established standards and practices while training at the
Facility.
i. To provide the necessary and appropriate uniforms and supplies required
where not provided by the Facility.
j. To wear a name tag that clearly identifies him/her as a student or faculty
member.
k. To sign a written agreement obligating the student or faculty member to
observe all rules and policies established by the Facility, to maintain the
confidentiality of patient information, and to refrain from publishing any
material related to the A.L.E. that identifies or uses of the name of the Board
of Regents, the Institution, or the Facility, directly or indirectly, or uses the
name of the Facility, without first obtaining written approval. Subject to the
right to publish set forth in section d above.
7. The Institution will require a11 student participants at the time of enrollment in the
A.L.E., if required and as necessary and appropriate during the period of participation,
to undergo a health examination, as will be necessary to determine that they are free
from any infectious or contagious diseases, and are able to perform their activities in
the A.L.E. program in order to ensure that students do not pose a direct threat to the
health or safety of others, which may include TB, PPD test or chest x-ray, hepatitis-B
core antibody test, and Rubella, measles and mumps tests or documentation of
immunization. At the option of the Facility, such health examinations may be
performed by the Facility, at the sole expense of the student participants. Any medical
or health care (emergency or otherwise) that may be received by an Institution
student or faculty member at the Facility in the course of the A.L.E. shall be at the
sole expense of the individual recipient of such care; provided that nothing herein
shall require the Facility to provide any such care. Any student or faculty participant
who does not meet the health criteria established by the Facility will not be assigned
to the Facility or allowed to continue to participate in the A.L.E. at the Facility. The
Facility has the right, at any time, to request health status reports on student and
faculty participants, to the extent allowed by applicable law. Moreover, if the student
and/or faculty member has an exposure to blood or body substances, if there is an
injury to the student and/or faculty member or if there is an infectious disease
outbreak, the Institution agrees, to the extent allowed by law, to send the student's
and/or faculty member's health records within two (z) business days of the receipt of
a written request by the Facility for such health records.
8. The Institution shall have the full responsibility for the conduct of any student or
faculty disciplinary proceedings and shall conduct the same in accordance with all
applicable statutes, rules, regulations and case law.
9. The Institution will assign faculty�staff representative(s� as liaison(s� between the
Facility and the Institution. The Institution faculty/staff representative(s) will be
designated in the Agreement.
E. MUTUAL RESPONSIBILITIES:
i. The parties will work together to maintain an environment of quality learning
experiences for the Institution's student(s), while at the same time enhancing the
resources available to the Facility for the providing of care to its clients and patients.
At the request of either party, a meeting or conference will be held between
: Institution and Facility representatives to resolve any problems or develop any
improvements in the operation of the A.L.E.
z. This working relationship and affiliation shall be reviewed annually by the parties.
This Memorandum of Understanding may be amended at any time by mutual
written agreement of the parties. It may also be canceled at any time by either party
upon not less than ninety (90) days written notice to the other party, but any students
currently in an A.L.E. may complete the A.L.E.
3. The Institution and the Facility acknowledge and agree that neither party shall be
responsible for any loss, injury or other damage to the person or property of any
student or faculty member participating in the A.L.E. unless such loss, injury or
damage results from the negligence or willful conduct of that party, its agents, officers
or employees.
4. This relationship is intended solely for the mutual benefit of the parties hereto, and
there is no intention, express or otherwise, to create any rights or interests for any
party or person other than Facility and the Institution; without limiting the generality
of the foregoing, no rights are intended to be created for any patient, student, parent
or guardian of any student, spouse, next of kin, employer or prospective employer of
any student.
5. Neither party is an agent, employee or servant of the other. The Regents, Institution,
and the Facility acknowledge and agree that student participants in the A.L.E. are not
employees of the Regents, Institution, or the Facility by reason of such participation,
and that they assume no responsibilities as to the student participants that may be
imposed upon an employer under any 1aw, regulation or ordinance. Student
participants shall in no way hold themselves out as employees of the Regents,
Institution, or the Facility.
6. Facility and Institution acknowledge that protection of participants in the A.L.E.
from exposure to bloodborne pathogens is the joint concern of Facility, Institution
and the participant. Facility wi11 make available to participants for use within the
Facility all personal protective equipment, including gloves, gowns, masks, and other
supplies necessary to comply with Centers for Disease Control guidelines, as
appropriate to the participant's A.L.E. If the A.L.E. involves exposure to bloodborne
pathogens, Facility shall provide participants with education regarding bloodborne
pathogens appropriate to the participant's educational training at Facility, and, shall
maintain documentation of such education. Institution shall, to the extent allowed by
law or regulation, offer to participants at substantial risk of directly contacting body
fluids, antibody and or antigen testing and vaccination in accordance with
requirements of the Occupational Health and Safety Administration and Centers for
Disease Control. Facility will use its best efforts to appropriately test the source
patient and to obtain that patient's consent to disclosure of test results to the
Institution and participant.
7. This Memorandum of Understanding shall be governed by, construed and applied in
accordance with the laws of the State of Georgia.
8. This Memorandum of Understanding shall supersede any and all previously executed
Memoranda of Understanding between the parties for applied learning experiences.
AGREED TO BY:
THE BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA
BY AND ON BEHALF OF
Augusta State UniversitX
� F��l v l Zo 1 I
Dr. Carol Ryc y Date
Acting Vice President for Academic Affairs
Au ust - ond Cou nt
� J
Sl�j��
h ��� Mr. Fred Russell Date
���
�C
Exhibit A
Institution and Facility Applied Learning Experience Agreement
This is an agreement on the part Augusta-Richmond County Government (hereinafter the
"Facility") and the Board of Regents of the University System of Georgia on behalf Au�usta
State University (hereinafter referred to as the "Institution").
t. WHEREAS, the Institution desires to obtain and the Facility desires to provide high
quality applied learning experiences for the Institution's students, while at the same
time enhancing the resources available to the Facility for the providing of care to its
clients and patients, through the operation of an applied learning experience
(hereinafter referred to as the "A.L.E.").
z. NOW THEREFORE, in consideration of the mutual covenants and promises
contained herein, the parties agree as follows:
This agreeinent applies to the following programs:
Department of Political Science B.E� in Political Science
Master af Public Administration IVI.P.A.
Departrnent of Sociology, Criminal Justice Bl�. Crirninal Justice
and Social Work
3. The Institution wi11 use its best efforts to provide the Facility with information
concerning the number of students, students' department/college, course of
instruction, and dates of participation, thirty (30) days prior to the commencement of
the A.L.E. When available, student names sha11 be provided prior to the students'
participation at the Facility. The Institution shall provide the number of faculty
participants and the faculty' department/college at least fifteen (z5) days prior to the
commencement of the A.L.E. Although the Facility may decline the acceptance of
student(s) or faculty, it will promptly notify the Institution of all students or faculty
who are accepted into the A.L.E. Further, the Facility sha11 provide the Institution
with written reasons for its non-acceptance of student(s� or faculty.
4. Upon receipt of the above information identified above in paragraph t., the Facility
sha11 designate the classroom or conference space, Facility personnel, and other
facilities or equipment appropriate for the A.L.E. and agrees to inform the Institution
of same. The Facility agrees to use its best efforts to provide additional facilities,
equipment and personnel as reasonably requested by the Institution. The availability
of additional facilities; equipment and personnel will be subject to availability, prior
requests for those resources, and the Facility's obligations regarding operation of the
" Facility.
5. If preceptors are used as an integral part of the A.L.E., evaluation(s) by the
Preceptor(s� will contribute to the evaluation of participating student practice
competency. The Preceptors will have appropriate licenses and degrees. The following
are specific Preceptor requirements:
Program Preceptor
Department of Political Science No Special Requirements
Master of Public Administration
Department of Sociolo�y Criminal Tustice
and Social Work
Institution students and faculty members have executed the following documents:
Check the applicable documents that have executed:
Authorization for Release of Records and Information
X Applied Learning Experience Agreement
X Agreement Concerning Faculty Supervision of an Applied Learning Experience
W hile a sample copy of each document is attached hereto and hereby incorporated by
reference, copies of each executed document are available upon request.
6. The following individuals will respectively serve as the faculty/staff representative(s)
for the Institution and the contact person for the Facility:
Pro r am: Department of Political Science and Master of Public Administration
Dr. Saundra Reinke
Phone: (706) 737-i7io Fax: (706) 667-4083
Address: Augusta State University
z5oo Walton Way
Augusta, GA 3o9o4-zzoo
7. In the event that an Institution or Facility contact person changes, the Institution or
the Facility, as appropriate, hereby agrees to promptly notify the other party of such
change.
Unless sooner canceled as provided herein, the term of this agreement shall be for a period of
three (3� years, commencing on February r, zoo9 and ending on February i, zoiz. This
agreement may be renewed or amended at any time by mutual written consent of the parties.
It may also be canceled at any time by either party upon not less than ninety (qo) days
written notice, but any students currently in an A.L.E. may complete the A.L.E.
NAME OF INSTITUTION: Augusta State University
C/ , L%l�'r F� � O L U /
� /
Dr. Carol Rychly Date
Acting Vice President for Academic Affairs
NAME OF FACILITY: Augusta- Richmond County Government
�---
c�n� gl a3�,�
A G� Mr. Fred Russell - Date
Administrator
S/�.�ir
Faculty Supervision Applied Learning Experience Agreement
In consideration for participating as an Applied Learning Experience (A. L.E.) educator of
students participating in any Facility where I may participate as an A.L.E. educator
(hereinafter referred to as the "Facility"�, I hereby agree to the following:
To follow the administrative policies, standards, and practices of the Facility when in the
Facility.
To report to the Facility on time and to follow all established regulations of the Facility:
To keep in confidence all medical, health, financial and social information (including mental
health) pertaining to particular clients or patients.
To not publish any material related to my participation as a supervisor in an applied learning
experience that identifies or uses the name of the Institution, the $oard of Regents of the
University System of Georgia, the Facility or its members, clients, students, faculty or staff,
directly or indirectly, unless I have received written permission from the Institution, the
Board of Regents of the University System of Georgia, and the Facility. However, the
Facility hereby grants to the Institution the right to publish Institution administrative
materials such as catalogs, course syllabi, A.L.E. reports, etc. that identify or uses the name of
the Facility or its members, staff, directly or indirectly.
To comply with all federal, state and local laws regarding the use, possession, manufacture or
distribution of alcohol and controlled substances.
To follow Centers for Disease Control and Prevention (C.D.C.) Universal Precautions for
Bloodborne Pathogens, C.D.C. Guidelines for Tuberculosis Infection Control, and
Occupational Safety and Health Administration (O.S.H.A.� Respiratory Protection
Standard.
To arrange for and be solely responsible for my Iiving accommodations while at the Facility.
To conform to the established standards and practices while training at the Facility.
To wear a name tag that clearly identifies me as a student.
Further, I understand and agree that, unless otherwise agreed to in writing; I will not receive
any monetary compensation from the Facility for any services I provide to the Facility or its
clients or patients, as art of my supervisory responsibilities at the Facility. Unless, otherwise
agreed upon in writing, I also understand and agree that I shall not be deemed to be
employed by or an agent or a servant of the Facility, that the Facility assumes no
responsibilities as to me as may be imposed upon an employer under any law, regulation, or
ordinance; that I am not entitled to any benefits available to Facility employees; and
therefore, I agree not to in any way hold myself.out as an employee of the Facility.
I understand and agree that I may be removed from the Facility based upon a lack of
competency on my part, my failure to comply with the rules and policies of the Institution or
Facility, if I pose a direct threat to the health or safety of others or, for any other reason the
Institution or the Facility reasonably believes that it is not in the best interest of the
Institution, the Facility or the Facility's patients or clients for me to continue.
I understand and agree to show proof of professional liability coverage in amounts
satisfactory to the Facility and the Institution pursuant to the terms and conditions of the
Georgia Tort Claims Act (O.C.G.A. §So-zr-zo et seq,�, anc� covering my activities at the
Facility; and to provide evidence of such coverage upon request of the Facility.
I further understand that all medical or health care (emergency or otherwise) that I receive at
the Facility will be my sole responsibility and expense.
I further understand and agree that, subject to the Facility's overall supervisory responsibility
for patient care, appropriately licensed Institution faculty members may provide such patient
services at the Facility as may be necessary for teaching purposes; that the nature and scope
of activities of Institution faculty members that may involve in any way patient care at the
Faculty shall be subject to the sole discretion of the Facility and to such conditions as the
Facility may deem necessary in its sole discretion including, but not limited to, prior proof of
professional liability coverage, appropriate licensure or certification, and compliance with all
Facility rules, regulations, and policies. I further understand and agree that if faculty
participation at the Facility other than as a Supervisor for the purpose of this applied learning
experience is so authorized, it must not be a substitute for adequate staffing at the Facility.
I have read, or have had read to me, the above statements, and understand them as they apply
to me. I hereby certify that I am eighteen (i8) years of age or older, am legally competent,
and that I have freely and voluntarily signed this "Agreement Concerning Faculty
Supervision of Applied Learning Experience".
This the day of
Participants Signature Witness Signature
Name (Please print� Name (Please print�
Student Applied Learning Experience Agreement
In consideration for participating in an applied learning experience (hereinafter referred to as
the "A.L.E.") at any Facility where I may participate in such an A.L.E. (hereinafter referred
to as the "Facility"), I hereby agree to the following:
To follow the administrative policies, standards and practices of the Facility when in the
Facility.
To report to the Facility on time and to follow all established regulations of the Facility.
To keep in confidence all medical, health, financial and social information (including mental
health) pertaining to particular clients or patients.
To not publish any material related to my A.L.E. that identifies or uses the name of the
Institution, the Board of Regents of the University System of Georgia, the Facility or its
members, clients, students, faculty or staff, directly or indirectly, unless I have received
written permission from the Institution, the Board of Regents of the University System of
Georgia, and the Facility. However, the Facility hereby grants to the Institution the right to
publish Institution administrative materials such as catalogs, course syllabi, A.L.E. reports,
etc. that identify or uses the name of the Facility or its members, staff, directly or indirectly.
To comply with all federal, state and local laws regarding the use, possession, manufacture or
distribution of alcohol and controlled substances.
To follow Centers for Disease Control and Prevention (C.D.C.� Universal Precautions for
Bloodborne Pathogens, C.D.C. Guidelines for Tuberculosis Infection Control, and
Occupational Safety and Health Administration (O.S.H.A.� Respiratory Protection
Standard.
To arrange for and be solely responsible for my living accommodations while at the Facility.
To provide the necessary and appropriate uniforms and supplies required where not provided
by the Facility.
To wear a name tag that clearly identifies me as a student.
Further, I understand and agree, unless otherwise agreed to in writing, that I will not receive
any monetary compensation from the Board of Regents of the University System of Georgia,
the Institution or the Facility for any services I provide to the Facility or its clients, students,
faculty or staff as a part of my A.L.E.
Unless otherwise agreed upon in writing, I also understand and agree that I shall not be
deemed to be employed by or an agent or a servant of the Institution, the Regents or the
` Facility; that the Institution, Regents and Facility assumes no responsibilities as to me as
may be imposed upon an employer under any law, regulation or ordinance; that I am not
entitled to any benefits available to employees; and, therefore, I agree not to in any way to
hold myself out as an employee of the Institution, the Regents or the Facility.
I understand and agree that I may be immediately withdrawn from the A.L.E. based upon a
lack of competency on my part, my failure to comply with the rules and policies of the
Institution or Facility, if I pose a direct threat to the health or safety of others or, for any
other reason the Institution or the Facility reasonably believes that it is not in the best
interest of the Institution, the Facility or the Facility's patients or clients for me to continue.
Such party sha11 provide the other party and the student with immediate notice of the
withdrawal and written reasons for the withdrawal.
I understand and agree to show proof of professional liability insurance in amounts
satisfactory to the Facility and the Institution, and covering my activities at the Facility, and
to provide evidence of such insurance upon request of the Facility.
I further understand that a11 medical or health care (emergency or otherwise) that I receive at
the Facility wi11 be my sole responsibility and expense.
I have read, or have had read to me, the above statements, and understand them as they apply
to me. I hereby certify that I am eighteen (t8) years of age or older, or my parent or guardian
has signed below; that I am legally competent to execute this Applied Learning Agreement;
and that I, or my parent and/or guardian, have read carefully and understand the above
Applied Learning Experience Agreement; and that I have freely and voluntarily signed this
"Applied Learning Experience Agreement".
This the day of
Participant Signature Witness Signature
Name (Please Print� Name (Please Print�
Parent/Guardian Signature Witness Signature
(if applicable)
Name (Please Print� Name (Please Print�