Student Experience Permission Form

Welcome to Experiences!

All students enrolled in experiences must complete this permission form with a guardian AND their instructor to ensure a smooth process.

There are three sections in this form you must complete.

Information about the student, mentor, and experience.
Student agreement of safety and workplace expectations. *Students must initial this section providing their consent.
Guardian consent to the child's participation. *Guardians must provide their signature at the conclusion of this form on behalf of their child and themselves.

Please note that the professional, or “mentor,” you choose to work with will need to undergo or have undergone a VLACS-initiated safety check UNLESS your parent or guardian will supervise your interactions with them. We take this step to ensure your safety.

If you would like to work with a professional who is already approved by VLACS, select one using our career mentor catalog.

After your guardian signs this permission form, they will receive an email to verify their signature. This step is required to complete the permission form.

The permission form, guardian signature, and safety check (if applicable) must be completed before you can work with your mentor.

Thank you for choosing VLACS!

Student Information

Please complete this section exactly as it appears in your Student Account

First Name

Last Name

Date of Birth

Please use mm/dd/yyyy format.

Confirm Email

emailValidation

Parent/Guardian Information

Please complete this section exactly as it appears in your Guardian Account

First Name

Last Name

Confirm Email

emailValidation

Instructor Information

Select your Instructor

Mentor Information

Is the Mentor you'd like to work with pre-approved by VLACS?

YesNo

Mentor First Name

Mentor Last Name

Mentor Email

Confirm Email

emailValidation

Experience Information

Competency Group

Will you be completing the experience virtually or on site?

On siteVirtual

Organization Information

Organization Name

Street Address

City

State

Zip Code

Will you be supervised by a guardian?

YesNo

Will you be paid minimum wage or greater?

YesNo

Attach a copy of your car and/or health insurance if traveling to site.

Are you, the student, willing to sign the media release to promote and celebrate your learning experience at this time?

YesNo

Hidden Fields

Opportunity Experience Record Type Id

Opportunity Primary Contact Id

Contact Constituent Record Type Id

Contact Student Record Type Id

Contact Guardian Record Type Id

Account Organization Record Type Id

to remove - Experience Information

Experience Type Hidden

Competency Group Hidden

Would you like to select from available Experiences offered by VLACS Professional Partners or submit your own?

Select from available ExperiencesSubmit my own Experience

Select an Approved Mentor

Mentor Contact Id

Available Offerings

Available Experiences

For the Experience Type and Competency Group selected above.

Mentor

Organization

Start Date

End Date

Location

Experience ID

Student Agreement

As a student, I understand and agree that I must:

Abide by the requirements of the Virtual Learning Academy Charter School (VLACS) for my participation in the learning experience.

Be responsible for my conduct at all times and that my participation may be terminated for any violation of the law, VLACS’s policies, any VLACS agreements, or the rules or policies of any sites accessed during the experience.

Communicate in a timely and professional manner.

Dress in a professional manner as appropriate.

Be on time for any appointments.

Follow all safety guidelines.

Only interact with the approved mentor(s) approved by VLACS safety checks policies for the purposes of my VLACS assignments, and not go beyond the scope of my learning experience selected.

Understand that my participation in the experience may include a site visit.

Limit my interaction with the listed mentor to fewer than 14 days.

Put my health and safety as the leading priority.

Have reliable and safe transportation to and from all related activities.

Contact the VLACS office immediately to notify them if there are any changes to the cleared mentor, Transportation Plan, or Learning Experience initially outlined to continue the Experience.

Always be within earshot or eyesight of at least one other adult beyond my mentor.

Report any uncomfortable engagements with mentor and others outside of the classroom. If for any reason I feel uncomfortable with an interaction with someone or feel unsafe, I will remove myself from the situation immediately and report this to my parent/guardian and my VLACS instructor before returning.

Recognize that VLACS cannot ensure my safety and cannot assume responsibility for any injuries sustained while participating in the experience.

Be responsible for my own safety and well-being while participating in the experience, and I or my parents (if I am less than 18 years old at the time of the signing of this agreement) shall bear all risk of loss or damage to my personal property and any risks of personal injury for participation in the experience.

Recognize that I may be doing tasks as part of the experience that have or may have various dangers and risks associated with it.
I agree to release, indemnify, and hold harmless VLACS, its trustees, and employees, from any and all claims and liability with regards to expense, loss of personal property, or personal injury that may occur during my participation.

I have read this document and acknowledge and understand the risks and requirements for me to participate.

As a student, I understand and agree to the above:

Yes, I understand and agree.

Student Initials

Potential Hazards

Please select any of the following hazardous occupations you may be working in:

Manufacturing or storing explosivesDriving a motor vehicle or work as an outside helper on motor vehiclesCoal miningOccupations in forest fire fighting, forest fire prevention, timber tract, forestry serviceOccupations in logging and sawmilling operationsPower-drive woodworking machinesExposure to radioactive substances and ionizing radiationPower-driven hoisting apparatusPower-driven metal-forming, punching and shearing machinesMining, other than coalPower-driven meat-processing machines, slaughtering and meat packing plantsPower-driven bakery machinesBalers, compactors, and power-driven paper-products machinesManufacturing of brick, tile and related productsPower-driven circular saws, reciprocating sawsPower-driven wood chippers, and abrasive cutting discsWrecking, demolition, and ship-breaking operationsRoofing operations and work performed on or about a roofTrenching and excavation operationsAgricultureNone of the above

Please list any additional dangers or risks associated with this learning experience or list N/A if none.

Transportation Information

How often will you be working on site?

0-2 times per week3-5 times per week6-7 times per week

Since you will be traveling on site and outside of the home, how will you get there?

I will drive myselfMy parent/guardian will drive meSomeone other than my parent/guardian will give me a rideI will use public transportationI will walk

Since you will be traveling on site and outside of the home, how will you get home?

I will drive myselfMy parent/guardian will drive meSomeone other than my parent/guardian will give me a rideI will use public transportationI will walk

Parent Agreement

As the parent/guardian of the student, I understand and agree that:

The student, my child, will abide by the requirements of the VLACS for their participation in the learning experience.
I grant my child permission to participate in the experience which may include a site visit.
I grant my child permission to participate in the experience which will include interaction with the listed mentor for fewer than 14 days.
My child’s participation is voluntary and is designed to give my child a learning experience that he/she may not otherwise experience while in school and that my child’s participation is a privilege and not a right.
My child is responsible for his/her conduct at all times and that my child’s participation may be terminated for any violation of the law, VLACS policies, any VLACS agreements, or the rules or policies of any sites accessed during the experience.
My child must remain a student in good standing in order to participate in the experience.
During the experience, my child may be performing tasks that have or may have various dangers and risks associated with it.
In consideration of the permission granted to my child to participate in this experience indicated above, I agree to release, indemnify, and hold harmless VLACS, its trustees, and employees from any and all claims and liability with regards to expense, loss of personal property, or personal injury that may occur during my child’s participation..

I have read this document and acknowledge and understand the risks and requirements for my child to participate.

As the parent/guardian, I understand and agree to the above:

Yes, I understand and agreeNo, I do NOT understand or agree