Student Placement Confirmation

Please complete this mandatory confirmation form in order to attend field placement. If there are any changes to your Field Placement please contact your Field Placement Specialist as soon as possible.

 

Student Information

000123456
Please provide a number you can be contacted at this semester (i.e. 905-575-1212)

Agency Information

Please be as specific as possible
The address of the main site you will be doing your placement NOT your home address. If you are working from home please just put "Working From Home"
Does this agency provide WSIB insurance to their paid staff?
You can get this information either from the placement confirmation email you may have received from your FPS or you can ask your Supervisor/Mentor.

Placement Information

What Program are you in?
What Semester is your placement in?
What Placement are you doing?

Terms and Conditions

Please carefully read the Terms and Conditions below.

1.ACKNOWLEDGEMENT: The candidate acknowledges that they have received, read, and understood and agree to the contents of the Student Field Placement Manual for the field placement in which they are registered for. The candidate agrees to comply, at all times, with the philosophy, practices, procedures and rules described in this document.

2.STUDENT CONDUCT: The candidate is familiar with, and agrees to act in accordance with the Mohawk College Student Behaviour Policy and other relevant Mohawk College policies. The candidate also agrees that while on field placement, they will comply with the rules, regulations and practices of the associate agency. The candidate will follow the role description provided and understands they are not to assume full responsibility of any tasks which are the obligation of a fully trained and qualified professional.  

3.PLACEMENT SELECTION: The Field Placement Specialist will initialize contact with the field placement site. Once approved, student candidates should arrange a meeting with the site and those who will oversee their progress to review expectations and timelines. While candidates will have opportunities to request preferred sites and locations, these selections are not guaranteed. Over the course of placement(s) candidates are required to gain experience in multiple areas and disciplines ? in some cases, varied placements are a requirement to graduate. Candidates should refer to specific program manuals for details.

4.SCREENING/CLEARANCE: The candidate is aware that medical screening, police clearance or other pre-requisites may be required to begin a field placement. Student candidates can acquire a letter from Mohawk College requesting Vulnerable Sector Screening to obtain such clearance at a reduced cost, but are encouraged to do so well in advance. Candidates should refer to specific program manuals for details.

5.CONFIDENTIALITY: The candidate understands that field placement agencies are required to comply with the regulations of the Freedom of Information and Protection of Privacy Act (FIPPA). The candidate therefore agrees to safeguard the confidentiality of personal information of children, staff, clients, and programs which they may acquire or be subject to during a field placement. No identification of specific persons shall be used in oral communication or written assignments associated with field placement assessment and evaluation. Candidates understand that failure to respect these privacies and maintain confidentiality could result in unsuccessful completion of the practicum and/or the program. No photography or electronic recording is permitted in the placement setting unless expressly permitted or agreed to in writing by the placement supervisor. Any student found in violation of this agreement may be removed from placement and will be sanctioned under Mohawk College "Student Behaviour Policy," up to and including termination.

6.FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY: The candidate understands that Mohawk College is also required to comply with the Freedom of Information and Protection of Privacy Act (FIPPA), which limits access to personal information, including educational history, without disclosure. The candidate understands that this agreement hereby authorizes Mohawk College to release their personal information to field placement agencies or prospective employers if requested to secure a practicum opportunity.

7.RELEASE: In consideration for services provided to the candidate by Mohawk College, and in particular relating to activities in field placement experiences, the candidate releases and agrees to indemnify Mohawk College from any and all claims which they may have, or may hereafter have, against the College for damages resulting from personal injury, losses or expenses of any kind, including damages to property arising out of, or in any way related to, their instruction as a student of the College, except for damages caused by the negligence of the College. In particular, the candidate agrees they are fully aware of the potential risks involved in field placements and thereby releases Mohawk College and its governors, officers, employees, agents and representatives from any liability. This release shall be binding upon the candidate and his/her heirs, executors and administrators.

8. STUDENT INSURANCE: The government of Ontario, through the Ministry of Colleges & Universities (MCU) reimburses the Workplace Safety & Insurance Board (WSIB) for the cost of benefits it pays to Student Trainees enrolled in an approved program at a Training Agency (Mohawk College). Ontario students are eligible for WSIB coverage while on unpaid work placements that are required by their program of study, if the placement employer is covered by WSIB (mandatory or by voluntary application coverage).

The MCU also provides private insurance coverage through CHUBB to students should their unpaid placement required by their program of study take place with an employer who is not covered under the Workplace Safety and Insurance Act, and limited coverage where placements take place outside of Ontario or Canada. Students are advised to obtain additional insurance coverage since as Chubb does not provide full compensation or coverage during non-work placement hours.

Please be advised that Mohawk College is required to disclose personal information to the Placement Employer relevant to the placement, limited to your full name, local address, telephone number and placement schedule. Personal information may also be disclosed to the MCU as related to the administration of a WSIB or CHUBBworkplace insurance claim.

Declaration

I have read and understand that WSIB or private insurance coverage will be provided through the Ministry of Colleges & Universities while I am on an unpaid work placement as arranged by Mohawk College as a requirement of my program of study. I understand that all accidents, injuries or illnesses sustained while participating in the unpaid work placement must be immediately reported to the Placement Employer and to my Mohawk College Placement Coordinator. A Postsecondary Student Unpaid Work Placement Workplace Insurance Claim form must also be completed in the event an insurance claim for an injury, illness or disease is submitted to the WSIB or CHUBB Insurance.

I acknowledge that I fully understand the nature and terms of this agreement. I understand that I have the right to obtain independent legal advice with respect to this agreement if I wish. I confirm that I am signing this agreement voluntarily and without duress.

I have read, understand and agree to the above Terms & Conditions