_____ Policy B-34
CONSEIL SCOLAIRE CATHOLIQUE FRANCO-NORD
TRANSPORTATION FORM FOR WORK PLACEMENTS IN COOPERATIVE
EDUCATION AND OTHER FORMS OF EXPERIENTIAL LEARNING
INSTRUCTIONS: For certain students who take part in cooperative education programs and in programs related to other
forms of experiential learning, access to transportation is of the utmost importance. Before being able to determine the
mode of transportation, this form must be signed by all concerned parties identified below.
GENERAL INFORMATION:
Student name: ____________________________ School: ____________________________
Name of employer (COOP work placement and others): ________________________________________________
Work placement period: 1st semester _____ 2nd semester _____ Summer _____
MODE OF TRANSPORTATION : (check all that apply)
_____ Walking
_____ Public transportation (city bus)
_____ Passenger in a vehicle. Specify: ________________________ (see NOTICE)
_____ Using own vehicle / parent’s vehicle (see NOTICE)
_____ Using an employer’s motorized vehicle (see NOTICE and complete the MTEL form)
NOTICE: Students assume all risks and legal liability when driving their own vehicle or that of their parents, and also
when they are a passenger in someone else’s vehicle when travelling to their work placement. Students using the
employer’s vehicle are covered under the automobile insurance policy of the employer, subject to all limitations or
exclusions of that insurance policy. The Conseil scolaire catholique Franco-Nord does not provide any automobile
insurance, liability insurance, accidental death insurance, disability insurance, dismemberment insurance or
medical insurance coverage to drivers and passengers of the vehicles.
By signing below, I acknowledge having read and understood the notice.
____________________________ _______________________________________________
Date Student Signature
____________________________ _______________________________________________
Date Parent/Guardian Signature
____________________________ ________________________________________________
Date School Principal Signature
____________________________ _________________________________________________
Date Teacher Signature
This form must be signed and given to the cooperative education teacher before the work placement begins or before establishing new dispositions regarding the work
placement. The funds available for the transportation of cooperative education students may vary from year to year.
According to the Municipal Freedom of Information and Protection of Privacy Act, 1989, the information contained in the forms and
documents regarding a student enrolled at the School Board is collected under the legal authority of the Education Act and related
regulations, and in accordance with the Ontario Student Record (OSR) Guideline.