{"id":703,"date":"2022-04-11T16:39:58","date_gmt":"2022-04-11T20:39:58","guid":{"rendered":"https:\/\/carleton.ca\/curatorial-studies\/?page_id=703"},"modified":"2022-04-11T16:43:32","modified_gmt":"2022-04-11T20:43:32","slug":"student-declaration-of-understanding-and-agreement","status":"publish","type":"page","link":"https:\/\/carleton.ca\/curatorial-studies\/student-declaration-of-understanding-and-agreement\/","title":{"rendered":"Student Declaration of Understanding and Agreement"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Student Declaration of Understanding and Agreement<\/h3>\n                            <p class='gform_description'><b>Workplace Safety and Insurance Board or Private Insurance Coverage For Students on Program-Related Unpaid Placements<\/b><br><br><b>Student coverage while on unpaid placement:  <u><b>Note: Prior to the start of the unpaid placement,<\/b><\/u> this Agreement must be completed AND submitted online by the student to indicate the Student Trainee\u2019s acceptance of the unpaid work placement conditions.<br><br>The Ontario Ministry of Colleges and Universities provides Workplace Safety and Insurance Board (WSIB) coverage for Student Trainees enrolled in an approved program at Carleton University and participating in unpaid work placements with employers who have WSIB coverage.<br><br>\r\n\u2022 The Ministry provides private insurance for Student Trainees and limited coverage for placements outside of Ontario (international or other Canadian jurisdictions).<br><br>\r\n\u2022 Carleton University has also arranged for private insurance coverage for students who attend placement opportunities that are not covered under either the WSIB or the Ministry\u2019s private insurance.<br><br>\r\n\u2022 Students are advised to maintain insurance for extended health care benefits through the CUSA\/GSA Student Health & Dental Plan or other group or private personal insurance plan. (http:\/\/carleton.ca\/health\/insurance\/)<br><br>\r\n<b>Please be advised that in the event of a workplace injury or disease where a claim is being made,Carleton University will be required to disclose personal information relating to the unpaid work placement and any WSIB claim or claim made through the Ministry\u2019s private insurer.<br><br><\/b> <\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/curatorial-studies\/wp-json\/wp\/v2\/pages\/703' data-formid='3' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_1\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_1\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Student Name and Carleton Student number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_3_1'>\n                            \n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_3_1_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.8' id='input_3_1_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_1_8' class='gform-field-label gform-field-label--type-sub '>Student Number<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_3_35\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_35\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name of Parent\/Legal Guardian (for students less than 18 years of age)<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_35'>\n                            \n                            <span id='input_3_35_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.3' id='input_3_35_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_35_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_35_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.6' id='input_3_35_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_35_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_33\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_33\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Visa Student<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_33'><li class='gchoice gchoice_3_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='YES'  id='choice_3_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_33_1' id='label_3_33_1' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='NO'  id='choice_3_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_33_2' id='label_3_33_2' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_4\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_4\"><label class='gfield_label gform-field-label' for='input_3_4' >Organization&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_34\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_34\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Estimated Number of Placement Hours<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_34'><li class='gchoice gchoice_3_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='144 as requirement for either CURA 5011 or CURA 5012'  id='choice_3_34_1'   aria-describedby=\"gfield_description_3_34\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_34_1' id='label_3_34_1' class='gform-field-label gform-field-label--type-inline'>144 as requirement for either CURA 5011 or CURA 5012<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='288 hours as requirement for both CURA 5011 and CURA 5012'  id='choice_3_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_34_2' id='label_3_34_2' class='gform-field-label gform-field-label--type-inline'>288 hours as requirement for both CURA 5011 and CURA 5012<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_34'>This placement applies to Graduate students registered in the Graduate Diploma in Curatorial Studies (Institute for Comparative Studies in Literature, Art and Culture, Carleton University) as part of their practicum course requirements. Please indicate whether the estimated number of hours covers a single course (either CURA 5011 or CURA 5012) or both (CURA 5011 and CURA 5012, taken consecutively over two academic terms).<\/div><\/li><li id=\"field_3_25\"  class=\"gfield gfield--type-consent gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_25\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Declaration and Agreement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_25.1' id='input_3_25_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_3_25\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_25_1' >I agree to the following (in lieu of signature)<\/label><input type='hidden' name='input_25.2' value='I agree to the following (in lieu of signature)' class='gform_hidden' \/><input type='hidden' name='input_25.3' value='7' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_25'>I hereby declare that I have read and understand that WSIB or private insurance coverage will be provided through the Ministry or by Carleton University while I am on an unpaid placement.<br \/>\n<br \/>\nI agree that, over the course of my placement, I will participate in, comply with all safety-related training and procedures provided by the Placement Employer.<br \/>\n<br \/>\nI agree that I will promptly inform my Placement Employer of any safety concerns. If these concerns are not resolved, I will contact my Departmental Co-ordinator at Carleton University and notify them of any unresolved safety concerns.<br \/>\n<br \/>\nI agree and understand that all workplace accidents sustained while participating in an unpaid work placement must be immediately reported to the Placement Employer and department of Risk and Insurance at Carleton University at &#x52;&#x69;&#x73;&#107;&#64;Ca&#x72;&#x6c;&#x65;&#116;&#111;n&#46;&#x63;&#x61;<br \/>\n<br \/>\nI also agree and understand that a Ministry Post-Secondary Student Unpaid Work Placement Insurance Claim form (https:\/\/www.forms.ssb.gov.on.ca\/mbs\/ssb\/forms\/ssbforms.nsf\/FormDetail?OpenForm&ACT=RDR&TAB=PROFILE&SRCH=&ENV=WWE&TIT=1352&NO=022-13-1352E) must be completed and signed in the event of any workplace injury and submitted to the department of Risk and Insurance at Carleton University at R&#105;&#115;&#x6b;&#x40;&#x43;a&#114;&#108;&#x65;&#x74;&#x6f;n&#46;&#99;&#x61;<br \/>\n<br \/>\nIn the event of an injury, I also agree to maintain regular contact with the department of Risk and Insurance at Carleton University at R&#105;&#x73;&#x6b;&#64;&#67;&#97;&#x72;&#x6c;e&#116;&#111;&#x6e;&#x2e;c&#97; and the departmental co-ordinator to provide all information relating to any restrictions and my ability to return to the placement.<br \/>\n<br \/>\nI understand the implications and consequences of consenting to this this agreement.<\/div><\/li><li id=\"field_3_36\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_36\"><label class='gfield_label gform-field-label' for='input_3_36' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_36' id='input_3_36' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   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