Cooperative Education
Site Agreement Form
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
STUDENT AND POSITION INFORMATION
Student Name Start Date/End Date
Student Position/Title
Days Per Week Hours Per Week Hourly Wage or Weekly Salary
I have agreed to work
July 2017/PR
www.manchestercc.edu/coop
SITE INFORMATION
Company/Agency/Organization Name
Supervisor’s Name, Title Department
Mailing Address
City State Zip
Phone Number Fax Number Email
REQUIRED CRITERIA FOR PARTICIPATION
Supervisor’s Signature Date
Student’s Signature Date
The on-site supervisor agrees to provide meaningful assignments and guidance related to the academic program of the student and to assist the student achieve learning objectives for the work
experience. The site will allow visits by the student’s academic advisor as needed and agrees to complete an evaluation form provided by the college that will assist the instructor in assigning
a grade. In addition, the site agrees to adhere to all federal and state regulations regarding employment, safety, worker’s compensation, child labor laws, minimum wage, and other applicable
regulations pertaining to employment of a student.
The student agrees to adhere to all standards of conduct, performance, ethics and respect for confidentiality appropriate to the profession and the site location.
