FIELD PLACEMENT FORM

Student name:
CCS School year:	eg 2021-2022
Proposal stage:

Proposal Stage: The student has filled out as much of this form as they can and submitted it to CCS program staff for approval in principle. Proposal deadline: June 15
Covenant Stage: The form has been revised and accurately reflects the terms and intentions of the field placement. It is ready for agreement by the student, CCS program staff, learning facilitator, and representative of the field placements site (eg. chair of board).

CONTACT INFORMATION

Student:
Phone numbers:	Email address:
Mailing address:
Field Placement:
Phone numbers:	Email address:
Mailing address:
Name and email of Placement site representative (eg. chair of board)
Learning Facilitator:
Phone numbers:	Email address:
Mailing address:
Mentor:
Phone numbers:	Email address:
Mailing address:
CCS Program Staff:
Phone numbers:	Email address:
Mailing address:	60 Maryland St, Winnipeg, MB, R3G 1K7

FIELD PLACEMENT DESCRIPTION

Field placement:
Theme focus:
Type of placement (congregational, community-based):
Briefly describe the site, including staff and key volunteers:
Describe any previous relationship with this ministry setting:
Will this placement overlap with paid employment?	If yes, describe lines of accountability between learning and performance goals:
Will there be a covenanting service or formal recognition?	If yes, provide details:
Have you submitted a Vulnerable Sectors police record check to the CCS Principal?:	A vulnerable sectors police record check is required for a CCS field placement.

PROPOSAL

The student will ensure that potential field placements know that CCS staff approval is required before a field placement is finalized.

Who have you consulted about this proposal so far? What has been the response?:
Do you have any concerns about this proposed placement or learning facilitator?:
Have you explored any other field placement possibilities?

LEARNING GOALS

A brief description of field placement related goals from the student's learning plan for the year. These might be more general at the Proposal stage and more defined for the Covenant stage.

Learning goals (Field placement related goals from the student's learning plan for the year. These might be more general at the Proposal stage and more defined for the Covenant stage.):
Learning opportunities, activities, and tasks anticipated as part of the placement, and how they relate to your goals:

LEARNING FACILITATION

When will the Learning Faciltator and student meet?:
What does the facilitator hope for and expect from the student?:
What does the student hope for and expect from the facilitator?:

LOCAL COMMITTEE

At the Covenant stage, the student will have identified 4 or 5 people connected with the placement to offer support and honest feedback.

When will the Local Committee and the student meet?:
Committee Member 1:
Phone numbers:	Email address:
Mailing address:
Committee Member 2:
Phone numbers:	Email address:
Mailing address:
Committee Member 3:
Phone numbers:	Email address:
Mailing address:
Committee Member 4:
Phone numbers:	Email address:
Mailing address:
add more as needed

COVENANT

When this form is at the Covenant stage it will be emailed to those involved for agreement. A fully signed version will be sent to all signers.

"I have reviewed the terms and intentions of the field placement herein outlined. I understand and appreciate the responsibilities of entering into covenant agreement in these field placement relationships. I have familiarized myself with the Field section of the CCS Student Kit and with CCS's Violence and Harassment Policy and agree to be governed by it. I commit to supporting this learning opportunity."

Date

Student signature: …
CCS Program Staff signature:
Learning Facilitator signature: