Cooperative Education and Internship Program (CEIP)College of Engineering 

Student Summary of Responsibilities Form

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I have read and understand the policies governing my participation in the Cooperative Education and Internship Program at the University of Massachusetts Dartmouth University and hereby apply for admission. If accepted, I agree to abide by the policy statements and responsibilities listed below as conditions for admission to and continuation in the program.

1.   * Enter and continue in the Cooperative Education and Internship Program in good faith and in fairness to both my employer and University of Massachusetts Dartmouth.
2.   * Maintain a satisfactory academic record with the the University of Massachusetts Dartmouth and a satisfactory job performance record with my employer.
3.   * Act in an ethical and professional manner as a representative of the University of Massachusetts Dartmouth and my employer.
4.   * Follow the required work session/academic session schedule of the Coop/Internship Program as specified by my College/Department.
5.   * Register for each of the required work sessions as specified by my College/Department and pay the required registration and service fee.
6.   * Submit the required Evaluation and Work Experience Reports to my Faculty Coordinator immediately after each work session.
7.   * Keep a current mailing address, phone number, and Email address with my Faculty Coordinator at all times.
Last Name   *
First/Middle Name   *   (First Middle)
Student Identification Number   *   (NOT your SSN)
School Email  *
Coordinator Last Name   *
Coordinator First/Middle Name   *   (First Middle)
I understand that under the Family Rights and Privacy Act of 1974, I have the right to inspect and review any records that are sent out of the University directly related to me. I hereby waive these rights regarding my resume, records, grades, or evaluations which:
(1) may be provided to an employer as the basis for my application for Coop/Internship employment;
(2) may be provided to or received from my Coop/Internship employer for the purpose of evaluating my progress while in the Coop/Internship Program.
Signature   (Please Initial Here)   *
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