Fill - Free fillable Student Self Selected Internship Site Placement Agreement (California State University Channel Islands) PDF form

CaliforniaStateUniversityChannelIslands

Student‐selectedInternshipPlacementSiteAgreement

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Student‐selectedinternshipSiteAgreementRev.1/2016

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Important:This AGREEMENT should only be used when a CSU Channel Islands STUDENT self‐

identifiesaninternshipopportunity,andrequeststoreceiveacademiccreditforworkperformed.

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ThisAGREEMENTpertainstooneSTUDENT’sinternshipopportunity.



The STUDENT is responsible for obtaining faculty approval, as well the signatures of authorized

signatories from both the INTERNSHIP SITE and the UNIVERSITY.Only UNIVERSITY  Procurement

staffcansignthisAGREEMENTonbehalfoftheUNIVERSITY.



InterningSTUDENT:    STUDENT’sPhoneNumber:

(FullnameofSTUDENT)



This AGREEMENT entered into between the Trustees of the California State University on behalf of

California State University Channel Islands, hereafter referred to as “UNIVERSITY,” and

_________________________,thereafterreferredtoasthe“INTERNSHIPSITE”.

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STATEMENTOFPURPOSE



INTERNSHIPSITEandUNIVERSITYrecognizetheop portunity formeaningfulSTUDENT‐focusedlearning

experiencesfortheUNIVERSITY,INTERNSHIPSITEandinterningSTUDENT(STUDENT).TheUNIVERSITY

supports the goals and objectives of the INTERNSHIP SITE program in which the STUDENT will

participate.



II. RESPONSIBILITIES

A. INTERNSHIPSITE’sresponsibilities:



1. California law may require the INTERNSHIP SITE to obtain STUDENT'S fingerprints and

 submitthemtotheDepartmentofJustice,and/ortheFederalBureauofInvestigation, for

 a  criminal background check. It is the INTERNSHIP SITE’s responsibility to: 1) determine

 whether such fingerprinting is required; 2) obtain the STUD

ENT's fingerprints; and 3)

 obtain criminal background clearance  from the appropriate agency, and 4) incur the

 costs offingerprinting.

2. Inform STUDENT of the need for a tuberculosis test; testing shall be at the expense of

 theSTUDENTorINTERNSHIPSITE;maintaintheconfidentialityofanyresultsasrequiredby

 federaland statelaw

.

3. Identify the STUDENT’s supervisor.The supervisor agrees to meet with the STUDENT

 regularly to facilitate the STUDENT’s learning experience, provide support, review

 progressandassignedtasks,verify

workhours andgive feedback. 

4. Provide an orientation that includes a site tour; an introdu

ction to staff; a

 description of the characteristics of and risks associated

 with the INTERNSHIP SITE’s

 operations,  servicesand/or clients;adiscussionconcerningsafety policies and emergency

CaliforniaStateUniversityChannelIslands

Student‐selectedInternshipPlacementSiteAgreement

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 procedures; and information detailing where STUDENTs check‐in and how they log their

 time.

5. ProvideSTUDENTwithawrittendescriptionoftheSTUDENT’stasksandresponsibilities.

6. Provide appropriate training, equipment, materials and work area for STUDENTs

 prior to STUDENTs performing assigned tasks or working with the INTERNSHIP SITE’s



 clients.

7. Evaluate the  STUDENT

 if requeste

d by the UNIVER

SITY and contact the UNIVERSITY if 

 theSTUDENTfailstoperformassignedtasksorengagesinmisconduct.

8. Notify the UNIVERSITY as soon as is reasonably possible of any injury or illness to a

 STUDENTparticipatinginalearningactivityattheINTERNSHIPSITE.

B. UNIVERSITY’sresponsibilities

1. AdvisethatSTUDENTagreestoparticipateinalltrainingrequiredbytheINTERNSHIPSITE.

2. AdvisethatSTUDENTagreestoexhi bitprofessional,ethicalandappropriatebehaviorwhen

 attheINTERNSHIPSITE.

3. Advise that STUDENT agrees to complete all assigned tasks and responsibilities in a

 timelyandefficientmanner.

4. Advise that STUDENT agrees to abide by the INTERN

SHIP SITE’s rules and standards of

 conduct.

5. Advise that STUDENT agrees to maintain the confidentiality of the INTERNSHIP SITE’s

 proprietaryinformation,recordsandinformationconcerningitsclients.

  6. The UNIVERSITY will advise STUDENT that neither the UNIVERSITY nor the

 INTERNS

HIP SITE assumes any financial

 responsibility in the event he/she is injured or

 becomesillasaresultofhis/herparticipationalearningactivityattheINTERNSHIPSITE.

7.ProvidetheSTUDENTwithgeneralandprofessionalliabilityinsuranceintheamountof

 $1,000,000peroccurrence,$3,000,000generalaggregate.Thisinsuranceisactivatedupon

 fullexecutionofthisAGREEMENT.

III.

GENERALPROVISIONS

A. ThisAGREEMENTwillbecomeeffectiveuponitsexecutionbybothINTERNSHIPSITEandUNIVERSITY,

 forthespecificperiodbeginningon,andendingon ,

 oruntilterminatedbyeitherpartyaftergivingtheotherparty30daysadvancewrittennoticeof

 theintentiontoterminate;however,anysuchterminationbytheINTE

RNSHIPSITEwillnotbe

effectiveagainstanyparticipatingSTUDENTuntiltheSTUDENT hascompletedtheinternshiptermor

asmutuallyagreeduponbytheparties.

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

CaliforniaStateUniversityChannelIslands

Student‐selectedInternshipPlacementSiteAgreement

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Student‐selectedinternshipSiteAgreementRev.1/2016

B.TheINTERNSHIPSITEandtheUNIVERSITYagreetoindemnify,defendandholdharmlesseachother

 fromanyandallliability foranypersonalinjury,da mages,wrongfuldeathorotherlossesandcosts,

 includingbutnotlimitedtoreasonableattorneyfeesanddefensecosts,arisingoutofthe 

 negligenceorwillfulmisconductoftheirrespectiveofficers,employees,agentsorvolunteersin



 theperformanceofthisAGREEMENT.Thisparagraphwillsurviveexpirationorterminationof 

 thisAGREEMENT.

C. Both theUNIVERSITYand INTERNS HIPSITE agree tomaintain general liability coverage of at least

$1,000,000 per occurrence, $2,000,000 aggregate and to provide evidence of coverage upon

request.Insuran

cemustbeplacedwithinsurerswithacurrentA.M.BestratingofatleastA:VII.

D. The INTERNSHIP SITE may dismiss a STUDENT if the STUDENT violates its standards, mission or

goals.TheINTERNSHIPSITEwilldocumentitsrationaleforterminatingaSTUDENTandprovidethe

UNIVERSITYwithacopyoftherationaleuponrequest.

E. The unpaid STUDENT

 participating in this internship at the INTERNSHIP SITE is not an officer,

employee,agentorvolunteeroftheUNIVERSITYortheINTERNSHIPSITE.

F. Nothing contained in  this AGREEMENT confers on either party the right to us

e the other party’s

name

withoutpriorwritte

permission,orconstitut

sanendorsementofanycommercialp roduct

orservicebytheUNIVERSITY.

G. This AGREEMENT may not be altered unless both parties agree in writing.The parties agree to

followallapplicablefederal,stateandlocallawsandregulations.

H. Anynoticesrequiredbythis AGREEMENTwillbede

emedtohavebeendulygivenifcommunicated

tothefollowingindividuals: 



UNIVERSITY:INTERNSHIPSITE:



        Name

 Faculty Advisor

(805)437‐ Telephone 

 



@csuci.edu EmailAddress

III.CSUPOLICIES,RULESANDREGULATIONS–TITLEIX

AsestablishedunderCaliforniaStateUniversityExecutiveOrders1096and1097,itisCSUpolicyto provide

equal opportunity for all persons regardless of race, reli gious creed, color, national origin, ancestry,

physical disability, mental disability,  medical condition, genetic information, marital status, sex, gender,

genderidentity,genderexpression,age,sexualorientation,andmilitary andveteranstatusin its programs 

and activities. UNIVERSITY provides equal accommodations, advantages, facilities,  privilege

s and services

forallmembersofthecampus community,as wellasthirdparties,initsprogramsandactivities.



INTERNSHIPSITEagreestoabidebyallCSUpoliciestotheextentsuchpoliciesapplyto UNIVERSITY

STUDENTs, staff, faculty and guests, including CSU policies prohibiting discrimination, harassment, and

CaliforniaStateUniversityChannelIslands

Student‐selectedInternshipPlacementSiteAgreement

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Student‐selectedinternshipSiteAgreementRev.1/2016

retaliationofallSTUDENTs,employeesandthirdpartiesinCSU educational programs and activities.CSU

ExecutiveOrders1096and1097areaccessiblehere:





 CSU Executive Order 1096 “Systemwide Policy Prohibiting Discrimination, Harassment,

 Retaliation, Sexual Misconduct, Dating and Domestic Violence, and Stalking against Employees 

 and Third Parties and Systemwide Procedure for Addressing Su

ch Complaints by Employees and

 ThirdParties”





 http://www.calstate.edu/eo/EO ‐1096‐rev‐6‐23‐15.html 



 CSU Executive Order 1097 “Systemwide Policy Prohibiting Discrimination, Harassment and

 Retaliation, Sexual Misconduct, Dating and Domestic Violence, and Stalking against STUDENTs

 andSyste mwideProcedureforAddressingSuchComplaintsbySTUDENTs”



http://www.calstate.edu/eo/EO‐1097‐rev‐6‐23‐15.html

    



UNIVERSITY shall respond promptly and effectively to all reports of discrimination,  harassment, and

retaliation, and will take appropriate action to prevent, correct, cease, and when necessary, discipline

behavior that violates this policy.Reports of possible discrimination, harassment or retaliation by

INTERNSHIPSITEwillresultintheimmediateterminationofthisAGREEMENTandimmediatede

partureof

the STUDENT from the INTERNSHIP SITE premises, regardless of the status of the UNIVERSITY’s

investigation.



INWITNESSWHEREOF,thisAGREEMENThasbeenfullyexecutedbythepartiesasofthedatelast

writtenbelow.



ForUNIVERSITYForINTERNSHIPSITE

_________________________________________ ____________________________________

Title:DateTitle:Date

Procurement&LogisticalServices

IUniversityDrive

CamarilloCA93012



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Student Self Selected Internship Site Placement Agreement (California State University Channel Islands)

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