Cooperative Education
Position Conversion Form
SITE INFORMATION
STUDENT POSITION CONVERSION INFORMATION
Company/Agency/Organization Name
Student Name Start Date/End Date
Please complete this form, sign, date and mail to:
Robert A. Henderson, Director of Cooperative Education, Manchester Community College, Great Path, MS #8, P.O. Box 1046, Manchester, CT 06045-1046
Email: rhenderson@manchestercc.edu Phone: 860-512-3312 Fax: 860-512-3371
Contact Person Name/Title Department
Student Position/Title Academic Program
Supervisor Name/Title Department
Days Per Week Hours Per Week Hourly Wage or Weekly Salary Benefits
July 2017/PR
www.manchestercc.edu/coop
Description of Present Job Responsibilities
Description of New Job Responsibilities/New Learning/Special Projects:
Training Comments
Mailing Address
City State Zip
Phone Number Fax Number Email
Phone Number Fax Number Email
REQUIRED
Supervisor Signature and Title Date
Continuing Notice of Nondiscrimination
Manchester Community College does not discriminate on the basis of race, color, religious creed,
age, gender, gender identity or expression, national origin, marital status, ancestry, present or
past history of intellectual disability, learning disability or physical disability, veteran status, sex-
ual orientation, genetic information or criminal record.
The following person has been designated to handle inquiries regarding the non-discrimination
policies: Debra Freund, Chief Diversity Officer, Manchester Community College, Great Path, P. O.
Box 1046, Manchester, CT 06045-1046, SSC L277. Manchester Community College is an Affir-
mative Action/Equal Opportunity Employer and strongly encourages the applications of women,
minorities, persons with disabilities, and veterans.
Continuando con el Aviso Anti-Discriminatorio
Manchester Community College no discrimina por motivos de raza, color, religión, credo, edad,
sexo, nacionalidad, identidad de género o expresión, origen nacional, estado civil, ascendencia,
historial presente o pasada de discapacidad intelectual, discapacidad de aprendizaje o discapaci-
dad física, estatus de veterano, orientación sexual, información genética o antecedentes penales.
La siguiente persona ha sido designada para manejar consultas relacionadas a nuestra póliza
anti-discriminatoria: Debra Freund, Directora de Diversidad en Manchester Community College,
Great Path, P. O. Box 1046, Manchester, CT 06045-1046; SSC L277. Manchester Community Col-
lege está bajo el plan de Acción Afirmativa / Empleador de Igualdad de Oportunidades y alienta
encarecidamente las aplicaciones de mujeres, minorías, personas con discapacidad y veteranos.
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