Cooperative Education Agreement

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Student/Employee_____________________________________________________________ Date ___________________

Student I.D # ____________________ Semester ________________ Curriculum __________________________________

Course number ___________________ Section _______


Am Using My Current Employer: ______ Yes ______ No


Is This A Family Operated Business: _____ Yes _____ No

Supervisor ____________________________________________________Phone ______________________________

(Supervisor Evaluating Student’s Co-op Work Experience Cannot Be Related to Student)

Employer Address _____________________________________________________________________________________

Faculty Coordinator ________________________________ Phone _______________


In consideration of the mutual benefits of the Coordinated Internship Program, the college, the employer and the student agree as follows:


Agrees to develop well-planned measurable learning objectives in conjunction with the Faculty Coordinator and the employer in relation to the goals of his/her instructional program. Student also agrees to abide by the college’s Coordinated Internship education rules and regulations and the employer and to immediately report to the Faculty Coordinator any problems occurring on the job or changes in job duties and responsibilities. Further, the student grants permission for the employer to discuss the student’s progress with the Faculty Coordinator. Student also agrees to inform the college’s Financial Aid Office of their Coordinated Internship employment and to report the wages earned during the coordinated internship work experience.


Agrees to provide the student with a supervised progressive work experience, assist the student in developing measurable learning objectives, provide orientation regarding company rules and regulations as well as inform student of company expectations. The employer further agrees to assure a safe and healthful working environment. Prior to the end of the semester employer will evaluate the student’s progress and that the time report reflects accurate hours worked. Employer further agrees to provide the student with a supervisor that is not related to the student.

Civil Rights and Non Discrimination Statement

It is the policy of the Virginia Community College System and Mountain Empire Community College to provide equal employment and educational opportunities for all persons without regard to race, color, religion, national origin, political affiliation, veteran status, gender, age, or sexual orientation and for all otherwise qualified persons with disabilities. This policy permits appropriate employment preference for veterans. This institution promotes and maintains educational opportunities without regard to race, color, sex, ethnicity, religion, gender, age (except when age is a bona fide occupational qualification), disability, national origin, or other non-merit factors.  This institution prohibits sexual harassment including sexual violence.

The following person has been designated to handle inquiries regarding non-discrimination policies: Ron Vicars, Vice President of Financial and Administrative Services. The following person has been designated to handle inquiries regarding student misconduct or equity issues based on gender: Lelia Bradshaw, Dean of Student Services. The following person has been designated to handle inquiries regarding employee misconduct or equity issues: Pam Giles, Human Resource Manager. For more information, contact 276.523.2400, 3441 Mountain Empire Rd., Big Stone Gap, VA, 24219. Virginia relay users dial 711.


Agrees to assign a Faculty Coordinator to assist the student in developing measurable learning objectives and make periodic contact with the employer. Faculty Coordinator will also determine a grade for the completed coordinated internship work experience and award college credit based on the student’s job performance and completion of required reports.

NOTE: Current Job Description must be attached.

_________________________________________________________      ______________

Student Signature                                                                                                     Date

_________________________________________________________     ______________

Faculty Coordinator Signature                                                                                Date

________________________________________________________       ______________

Employer Signature                                                                                                 Date