Covenant Agreement for Field Placement: 
This form is to be filled out by the student, the Learning Facilitator and the Diaconal/Vocational Mentor in the first weeks of the field placement.  Students are to submit this form to the CCS Program Administrator - by first day of Fall Learning Circle.  Please retain a photocopy of the signed document for your records.	

Theme Year:

Student
Name:	
Street Address:
City:		Province:	Postal Code:
Phone: (W)	Fax:	e-mail
	(H)

Theme Year Field Site
Name:
Street Address:
City:		Province:	Postal Code:
Phone: (W)	Fax:	e-mail
	(H)

Learning Facilitator
Name:
Address:
City:	Province:	Postal Code:
Phone: (W)	Fax:	e-mail
	(H)

Diaconal/Vocational Mentor
Name:
Address:
City:	Province:	Postal Code:
Phone: (W)	Fax:	e-mail
	(H)

Learning Goals of the Student (please attach final draft of theme year Learning Plan)
From theme year Learning Plan, please isolate the major learning goals related to the field placement:

Learning Opportunities and tasks in the field placement
Please list the learning opportunities and tasks envisioned in this field placement:

Learning Facilitation
When will the Learning Facilitator and student meet?

What does the Learning Facilitator expect from the student? (record keeping, communication, written materials, etc.)

What does the student expect from the Learning Facilitator? (feedback, regular meetings, etc.)

Will there be a service of covenanting/formal recognition of the student’s presence with the ministry/agency setting? What will that be? When will that happen?

We understand and appreciate the responsibilities of entering into covenant agreement in these field placement relationships. 

Student:________________________________ Date:______________________
			(signature)

Learning Facilitator:______________________ Date:______________________
			(signature)

Chair/Representative
from Vestry/Board/Council:________________ Date:______________________
			(signature)

Contact information:
Local Committee:
Name:
Street Address:
City:		Province:	Postal Code:
Phone: 	Fax:	e-mail

Name:
Street Address:
City:		Province:	Postal Code:
Phone: 	Fax:	e-mail

Name:
Street Address:
City:		Province:	Postal Code:
Phone: 	Fax:	e-mail

Name:
Street Address:
City:		Province:	Postal Code:
Phone: 	Fax:	e-mail

Acknowledgement of CCS Harassment Policy and Procedures Form

After reviewing the excerpts of the CCS Harassment Policy and Procedures document, (the full document is located on the CCS website at www.ccsonline.ca), sign and return a copy of this form to the CCS Program Administrator by the first day of the Fall Learning Circle.

Name of Student: __________________________________________

Name of Diaconal/Vocational Mentor: __________________________

Name of Learning Facilitator: _________________________________

We understand and appreciate the responsibilities of entering into a learning relationship.  We have reviewed together the Harassment Policy of the Centre for Christian Studies and we understand that it is to govern our behaviour and relationship.

Student: _____________________________________	Date:________________
		(signature)

Diaconal/Vocational Mentor: _____________________	Date:________________
		(signature)

Learning Facilitator: ____________________________	Date:________________
		(signature)

This signed document has an important legal status regarding the Harassment Policy and must be on file at CCS.  (When this form is signed and completed copies should be retained by the student,  Learning Facilitator and Vocational Mentor; and copies sent to the Local Committee and Program Administrator.)