Career Services
Cooperative Education/Internship Program
Permit to Register
The student is responsible for completing this form and obtaining the faculty adviser signature. The original must be
returned to the Career Services Center (SSC 3258), who will facilitate the registration process once all necessary forms
are received.
COD ID
Social Security Number X X X - X X -
Student Name:
Address:
Telephone: (h)
(c)
Email:
Are you authorized to work in the U.S.A.? International Student Adviser Approval:
As a student participating in the Cooperative Education/Internship Program offered by College of DuPage I agree to
indemnify and hold harmless College of DuPage, its agents and employees, from any claims, liability or causes of action
which may be asserted against College of DuPage, its agents or employees, for personal injury or property damage
sustained by me in the course of participation in the Cooperative Education/Internship Program. I understand that by
participating in these programs I may be deemed to be an employee of the company to which I provide services but I
am not an employee of College of DuPage. I, therefore, acknowledge that I am not entitled to any benefits or privileges
extended to College of DuPage employees. I will strive to meet or exceed performance expectations and learning goals.
STUDENT SIGNATURE DATE
FIELD OF STUDY/ACADEMIC AREA COMPANY SUPERVISOR NAME
WORK EXPERIENCE TITLE COMPANY NAME
PAID UNPAID COMPANY ADDRESS
FACULTY ADVISER NAME CITY/STATE/ZIP
FACULTY ADVISER SIGNATURE COMPANY TELEPHONE
CREDIT HOURS REQUESTED SUPERVISOR EMAIL
TO BE COMPLETED BY CEIP STAFF
Course Code -
2
- cp Credit Hours
CEIP STAFF SIGNATURE
Career Services Center | SSC 3258 | 425 Fawell Blvd. | Glen Ellyn, IL 60137-6599 | (630) 942-2230
College of DuPage
Term
Start Date
End Date
Hours per Week
CARSERV-13-12205(R3/13)
