DCE Night School Cooperative Education Application Form 2020
Durham Continuing Education Night School
Cooperative Education Placement Information Form
Must be received by Durham Continuing Education no later than Wednesday Feb 5, 2020 3:00 pm
Program Type (select one)
Paid Employment Unpaid Placement
Demographics (Basic Student Demographics)
Name (print clearly)
Date of Birth (dd/mm/yyyy)
Gender (I identify as):
Male Female
Address: City:
Postal Code:
Contact Number(s):
Home: __________________________________
Cell: __________________________________
Parent/Guardian #1 (name)___________________________
(for students 18 year of age or less)
Contact # ___________________________
Emergency Contact (name)___________________________
(for students over 18 years of age)
Contact # ___________________________
Email: (print clearly)
Home School:
The information collected on this application is done under the authority of the Education Act, 1990 and will be used for the purposes
of determining suitable candidates for the program, enrolling students in the program, and matching the students to an appropriate
cooperative education placement. It is necessary for the Durham DSB to share the names, contact information, and academic
achievements of the students with the supervisors at the cooperative education placement. By submitting this application form, you
are consenting to the Durham DSB sharing information contained in this application form as required.
It is the responsibility of the student to secure employment or a suitable placement prior to the start of the course. The Night School
Cooperative Education teacher will contact the placement/employment to ensure a safe, healthy and challenging learning
environment and to confirm schedule and placement/employer responsibilities.
Employment/Placement – Name of Company/Organization
Name AND Phone Number of Contact Person
Co-op History and Related Information
Is this co-op placement for a Specialist High Skills Major
Program (SHSM)? Yes
If yes, what is the major area (sector) – Area of specialty?
Why have you decided to participate in the night school cooperative education program?
Selection Criteria for Students who are participating in this program:
16 years of age or older and have completed minimum 16 credits
Placement or employment MUST be within Durham Region
Students with paid employment must be guaranteed a minimum of 8 hours per week (which may include
weekends) some of which must fall on either a Monday or Wednesday evening between 6:00 PM – 9:00 PM
Students with an unpaid placement must be guaranteed volunteer placement hours on Monday and
Wednesday between 5:30 PM – 9:30 PM
Employers/Placements must agree to co-op teacher monitoring on site
Students must attend all in-class sessions.
Contact: Night School Cooperative Education, 905.436.3211 email: michele.reid@ddsb.ca
DCE Night School Cooperative Education Application Form 2020
Terms and Conditions for Night School Cooperative Education Program
Night school cooperative education begins Wednesday February 12, 2020 at 6:00 PM and concludes on
Wednesday June 3, 2020 at 9:00 PM
Students may be paid or unpaid during the cooperative education program
Students are responsible for transportation to and from the placement/employment
Students attend the placement/employment for a minimum of 8 hours weekly – see selection criteria
Students are required to recruit and secure their placement/employment. The night school cooperative education teacher
will contact the recruited placement/employer prior to the first day of the placement to confirm suitability. Suggestions for
placement opportunities may be obtained in consultation with the home school (Note: DCE and the home school are not
responsible for securing placements), neighbours, parents and relatives.
Students must complete and submit the application form - incomplete forms will not be considered
Students will be contacted at his/her home phone number by the cooperative education teacher
Students will be required to attend all days for the pre-placement and integration sessions. Absence may mean that your
start date at the placement is delayed or cancelled.
Students will be required to complete assignments during the placement/employment component.
The Co-op Teacher may be required to provide pertinent information about the student to a perspective
Students MUST not drive any motorized vehicles (ATV, forklift, car, truck, boat, etc.) while attending the placement (unpaid
placement only)
Students may be required to wear personal protective equipment and may be removed from the placement if they fail to
comply with the rules.
Students must maintain strict confidentiality regarding matters at the placement/employment
Theft, vandalism or crimes are grounds for termination of the placement and/or removal from the program with loss of credits
and/or possible further action under the law
If the supervisor terminates the placement/employment, you may be terminated program and will forfeit the co-op credit.
Students must attend the placement/employment as agreed upon and outlined on the Work Education Agreement
Students must report all absences to the placement/employer AND to the Cooperative Education Teacher at the
beginning of each day, stating reason for absence.
Medical appointments, family vacations and part time jobs must be scheduled outside of class time. Credits are
earned based on the achievement of expectations related to the Co-op credit and attendance for the required amount of time
at the placement/employment. All assignments and expectations must be completed by the last date of the program as the
cooperative education teacher will not be available after the final date of the program. The program cannot be fast tracked.
If you have a medical condition that may affect the placement/employment, students must disclose this information to the
cooperative education teacher, prior to the start of the placement/employment.
Students must observe all health and safety regulations at the placement/employment and report any health and safety
concerns immediately to the cooperative education teacher.
Students will be provided with Workplace Safety and Insurance (WSIB) by the Ministry of Education while attending the
cooperative education placement. Students with paid employment MUST have WSIB covered by the employer.
I understand that I can be removed from the cooperative education program with loss of credit, if I am unable to meet the program
requirements in either the classroom component or the placement/employment component.
I have read the schedule for Night School and am aware of the start and end dates for this night school course. I am aware I will
earn one credit upon successful completion of the course.
I agree to the above terms as indicated by my signature.
Student Signature:
(For students under 18 years of age) I understand that my daughter/son is enrolling in a night school cooperative
education program which will involve substantial time in the community. I understand that my daughter/son must
adhere to the above terms.
Parent/Guardian Signature:
Return the completed application form to Durham Continuing Education to complete the registration process
by the registration deadline. Fax: 905.436.1780
Contact: Night School Cooperative Education, 905.436.3211 email: michele.reid@ddsb.ca