Experiential Learning Placement Form

Student Information
Lucia Sanchez
Student #1: ___________________________________________

(902) 314-6955
Phone: _________________________

luciasanchez.124@gmail.com
Email: _______________________________________________________________________________________

Jen White
Student #2: ___________________________________________

Phone: _________________________

Email: _______________________________________________________________________________________

Anyssa Gangon
Student #3: ___________________________________________

Phone: _________________________

Email: _______________________________________________________________________________________

U203 Leadership
Course: ______________________________________________________________________________________

Inge Dorsey
Instructor: ___________________________________________________________________________________

Community Partner Information

UPEI Athletics
Community Partner: ________________________________________________________________________
Chris Huggan
Supervisor: ______________________________________

Director, Athletics and Recreation

Position: _______________________

chuggan@upei.ca
Email: _____________________________________________

(902) 566-0715
Phone: _________________________

Address: __________________________________________

Chtown
City/Town: ____________________

PEI
Province: __________________________________
________

Postal Code: ___________________

Experiential Learning Placement Details

Event Coordinator
Student (s) Position/Title: _________________________________________________________________
Feb. 2/15
Start Date: ________________________________

March 21/15
End Date: ______________________________

15+
Hours/Schedule to be completed: ________________________________________________________
Organizing a dodgeball tournament
Duties/tasks to be performed: ____________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Experiential Learning Agreement

The Student(s) will:
Perform duties/tasks outlined in the description above on a voluntary basis
Enter into the placement with a positive attitude and willingness to learn
Respect policies of the Community Partner with regards to dress code,
attendance and safety regulations
Notify the Community Partner and Instructor if you are going to be absent or
late, of any concerns injuries, accidents or errors
Agree to be under supervision of a placement supervisor
Maintain privacy and confidentiality
Perform duties/tasks during the agreed upon schedule
Self evaluate, reflect and complete final project for course credit
Complete the online form in the Experiential Learning Portal
Lucia Sanchez
Name: ______________________________________________

Feb. 5/15
Date: ___________________________

Name: ______________________________________________

Date: ___________________________

Name: ______________________________________________

Date: ___________________________

The Instructor will:

Provide students with the classroom component of the course and any prerequisite skills needed before a placement can begin
Ensure the students are placed in a safe environment and getting the training
needed to perform duties/tasks described above
Supervise/support the student throughout the placement via onsite visits or
one-one meetings
Grant credit to the student upon the successful completion of acceptable
coursework and performance evaluations from the Community Partner and
Instructor
Complete the online form in the Experiential Learning Portal

Name: ______________________________________________

Date: ___________________________

The Community Partner & Supervisor will:

Provide a safe learning environment that engages the student with meaningful
and progressive tasks that allow career exploration/skill development
Designate one employee to be the direct Supervisor for the student
Monitor students abilities, attitude, and skill development
Provide encouragement and/or corrections when necessary
Provide an orientation
Provide any training/equipment required to perform duties/tasks outlined
above
Places an emphasis on reciprocal learning
Report all concerns, injuries, or accidents to the Instructor
Not engage/hire/employ the student to replace a paid employee
Agree to complete an evaluation upon the conclusion of the placement
Complete the online form in the Experiential Learning Portal
Name: ______________________________________________

Date: ___________________________

Experiential Learning Placement Tracking

Please use the form below to track and verify the hours spent on your Experiential
Learning Placement. This form must be signed by both the student and the supervisor
from the Community Partner. Form must be submitted to your instructor at the end of
your Experiential Learning Placement.
Lucia Sanchez
Student: ______________________________

Week 1

Community Partner: UPEI Athletics

______

Week 2

Week 3

Week 4

____

Week 5

Sunday
Monday

Tuesday

Text
Text
2

Wednesday
Thursday

11 1

Friday
Saturday

6
20
Total Hours __________

NOTE: All absences must be noted on the chart.

By signing this document you verify that the student has completed the hours noted
above for credit in the Experiential Learning Placement.
Supervisors Signature:

__________________________ Date: ________________________

Experiential Learning Glossary

Experiential Learning: Experiential learning is a philosophy and methodology in
which educators purposefully engage with students in direct experience and focused
reflection in order to increase knowledge, develop skills, and clarify values.
(Association for Experiential Education)
Experiential learning is also referred to as learning through action, learning by doing,
learning through experience and learning through discovery and exploration.
(Experiential Learning, Northern Illinois University, Faculty Development and
Instruction Design Centre)
Student: The individual providing work/service outside the classroom setting.
Community Partner: This is the business, organization, group, etc. with which the
student will be providing service/work.
Supervisor: The individual responsible for overseeing the student while they
complete their service/work at the Community Partner. They would be responsible
for providing feedback and completing an evaluation for the student.
Instructor: This could be the professor/teacher/or another individual related to the
course in which the student is enrolled. They would be the contact person at the
university.
Service Learning: It is a teaching method that promotes student learning through
active participation in meaningful and planned service experiences in the community
that are substantively related to course content. Through reflective activities, students
enhance their understanding of course content, general knowledge, sense of civic
responsibility, self awareness and commitment to the community. (Zachary Gifford,
Associate Director Systemwide Risk Management and Public Safety, CSU)
Service-learning is significantly different from other forms of experiential learning
because it focuses on service and learning objectives, reciprocal learning, civic skills,
community concerns, and community involvement.
Internship: A professional working position which enables the intern to gain
valuable work experience and on-the-job training. Some internships are paid
positions, while others are unpaid. Both allow you to work within an organization to
gain first-hand experience about a particular industry or field of work.
(www.youth.gc.ca)
An internship formally integrates the students academic study with practical
experience in a cooperating organization. It is an off-campus activity designed to
serve educational purposes by offering experience in a service learning, business,
non-profit or government setting...(EO 1064, CSU)