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School of EducationClinical Practice Access Agreement

Learner Instructions
tab to each of the highlighted fields and fill in the appropriate information (required). print the agreement and obtain the necessary signatures on the last page of this agreement. Complete the agreement with your signature and fax to 1.888.227.8492.

Learner Contact Information

Salmon
learner last naMe (please type)

Sabrina
First naMe

M
Middle initial

1241735/6975
learner id/last FoUr digits oF ssn (reqUired)

LEA
prograM/speCialization

SSALMON1@CAPELLAUNIVERSITY.EDU
eMail address

405-602-5340
phone nUMber

Oklahoma City, OK USA

City, state, and CoUntry oF residenCe

Capella University | Capella tower | 225 soUth sixth street, ninth Floor Minneapolis, Mn 55402-3389 | 1.888.Capella (227.3552) | www.Capella.edU

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School of EducationClinical Practice Access Agreement

Background and Purpose of Agreement

this agreement is established between Capella University (hereafter referred to as Capella or Capella University), Sabrina Salmon , (hereafter referred to as the Candidate), and Douglass High School (hereafter referred to as the site) for the purpose of establishing guidelines for the cooperative provision of clinical practice within educational settings for students enrolled in Capellas education training programs. Capella University is an on-line university based in Minneapolis, Minnesota. since 1997, Capella has been fully accredited* by the higher learning Commission and is a member of the north Central association of Colleges and schools. the Candidate is a student in good-standing at Capella. the Candidate is enrolled in the Doctor of Education in education, specializing in Leadership in Educational Administration Capella masters level or doctorate programs in education and is successfully progressing in his/her educational program such that he/she is qualified to undertake the clinical practice the site is able to provide. General Provisions Definitions: a. Clinical practice consists of defined training activities required in order for completion of the Candidates course of study. these programs afford the student the opportunity to practice skills and utilize the competencies gained during the Candidates course of study. b. University supervisor is the faculty member instructing the Candidate within the course he/she is enrolled simultaneously during clinical practice. serving as a liaison with the Candidate, site supervisor, and with the site for clinical coordination. C. the site supervisor is the cooperating site employee who provides on-site supervision to the trainee. d. the Clinical training Faculty lead is school of education faculty member who has reviewed and approved the clinical practice application, and is the university representative as the signatory on this document. e. the Candidate, as the term is used in this agreement, is understood to refer to a university learner enrolled in an education training program at Capella University. F. all communication to the University supervisor should be directed to the preferred contact method of the University supervisor, the Clinical training Faculty lead or soeclinicalexperience@capella.edu The parties mutually acknowledge and agree as follows: a. the Candidate understands that clinical activities in relation to completion of their program of study are covered through a policy of insurance issued to Capella. however, any activities deemed to be outside the scope of the approved clinical practice, will be solely the responsibility of the Candidate or the site. in the event a claim is made which is determined to be outside the scope of Capellas insurance coverage, the Candidate and site agree to hold Capella harmless from any and all losses. b. to exchange information necessary for review and approval of essential Candidate learner outcomes, professional activities, experiences to be included, and professional materials to be utilized during clinical practice. C. Capella, in cooperation with the site, will be permitted to contact the site for the purpose of obtaining agreement of the sites employed professionals to serve as site supervisors. these site supervisors shall provide supervision of the activities performed by the Candidate. d. the site will have the authority to terminate an individual Candidates clinical experience for cause, including violation of site rules of professional conduct by the Candidate.

aCCreditation

CaPella University

Capella University is accredited by The Higher Learning Commission and is a member of the North Central Association of Colleges and Schools (NCA), www.ncahlc.org.

Capella Tower, 225 South Sixth Street, Ninth Floor Minneapolis, MN 55402 1.888.CAPELLA (227.3552), www.capella.edu
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Capella University | Capella tower | 225 soUth sixth street, ninth Floor Minneapolis, Mn 55402-3389 | 1.888.Capella (227.3552) | www.Capella.edU

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School of EducationClinical Practice Access Agreement

Responsibilities
Capella University agrees: 1. to review and approve the Candidates Clinical practice application and other related documentation prior to the start of clinical practice activities at the proposed site. 2. to prepare Candidates for clinical practice experiences by means of coursework designed to familiarize them with methods and protocol. 3. to assign a Capella University supervisor to facilitate communication among the University, the Candidate, and the site supervisor. the online clinical practice courseroom faculty is the Capella University supervisor. 4. to provide the site supervisor the following materials: All evaluation forms required at the end of the supervised clinical experience. Contact information for the University Supervisor and Clinical Training Faculty Lead. 5. to maintain regular contact between the University and site supervisor, to consist of at least electronic and phone contact at the beginning, middle, and end of the clinical experience. 6. to notify the Candidate that he/she is responsible for complying with all policies and procedures governing Candidates at the site, and that he/she is required to conduct him/herself according to the professional and ethical standards of an educator. 7. to provide immediate consultation with the University supervisor should disagreements arise between the Candidate and the site supervisor (acknowledging that the site supervisor has primary authority for all activities of the Candidate at the site). The Site and Site Supervisor Agrees: 1. to verify the chosen site supervisor(s) has the appropriate time and ability to commit to supervision of the Candidate. 2. to provide opportunities for the Candidate to engage in activities necessary to complete the Candidates clinical practice and course of study. 3. to provide the learner with adequate workspace to carry out the clinical experience. 4. to maintain regular communication with Capellas University supervisor and to communicate any concerns to the University supervisor or Clinical training Faculty lead in a timely manner. 5. to notify the University supervisor immediately if there are any changes to the Clinical practice application including dates, hours, supervision, etc. The Candidate Agrees: 1. to immediately notify the University supervisor, Clinical training Faculty lead, or soeclinicalexperience@capella.edu of any Changes to the Clinical practice application including dates, hours, location, supervision, etc. 2. to abide by Capella University learner Code of Conduct (policy 4.02.02 in the Capella University Catalog) and all appropriate protocols relating to their clinical experience. 3. to conduct oneself according to community standards as an educator at all times during the clinical experience, and to adhere to the rules, policies, regulations, and standards of the site. 4. to notify the site supervisor(s), University supervisor, and Clinical training Faculty lead of any relevant impairment of competence to perform as expected during the clinical experiences, whether the impairment arises from physical, psychological, or other causes. 5. to obtain any additional training and/or education deemed necessary by the site supervisor(s), University supervisor, and Clinical training Faculty lead in order to conduct the clinical experience at a minimum standard of competence. 6. to represent oneself as a Candidate during appropriate times during the clinical experience placement.
Capella University | Capella tower | 225 soUth sixth street, ninth Floor Minneapolis, Mn 55402-3389 | 1.888.Capella (227.3552) | www.Capella.edU
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School of EducationClinical Practice Access Agreement

term of the agreement this agreement shall be effective from 4 / 4 / 11 to 9 / 16 / 11 . and may be extended through the mutual agreement of the parties. Waiver of liability. each party to this agreement agrees to hold the other parties harmless for any losses, injuries or other damages incurred as a result of activity undertaken pursuant to the fieldwork described herein. it is recognized that this waiver of liability does not in any way affect the rights to remediation afforded under any policy of insurance. Waiver of rights under the Family education rights and Privacy act the parties understand that all activities are undertaken as an educational experience required for completion of trainees program of study at Capella University. as such, proper evaluation of performance and development is required. trainee agrees that it is necessary for the University supervisor and site supervisor to openly communicate regarding trainees activities, competencies and other matters relating to the clinical experience. trainee agrees to this communication and waives any rights restricting this exchange of information. right to Counsel. in executing this agreement each party acknowledges that they have read the document and have had the opportunity to consult with legal counsel. Jurisdiction and venue. this agreement shall be subject to the laws of the state of Minnesota and all action in relation to the terms hereunder shall be venued in the Federal district Court located in hennepin County, Minnesota. severability. any portion of this agreement that is deemed to be unenforceable may be severed from the agreement with the effect of the remaining portions of the agreement being fully enforceable by the parties. entire agreement. this agreement reflects the entire agreement between the parties and supersedes all other agreements, whether oral or written. no part of this agreement may be amended except by written agreement signed by the parties. execution. this agreement may be executed in counterparts and via facsimile with each part being considered an original and all parts being recognized as one in the same document. executed this
3

day of

February , 20 11 .

Capella University | Capella tower | 225 soUth sixth street, ninth Floor Minneapolis, Mn 55402-3389 | 1.888.Capella (227.3552) | www.Capella.edU

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Signature Page
site supervisor agreement i, Gregory Brian Staples , the site supervisor assigned to this learner, agree to provide professional supervision for this clinical experience. i agree to submit all required forms by the end of the quarter in which the clinical experience is completed. i understand that Capella University does not compensate site supervisors for their services and that any such compensation is provided by the site. signatures
Sabrina Salmon
learner naMe

Sabrina Salmon
learner signatUre

Digitally signed by Sabrina Salmon DN: cn=Sabrina Salmon, o, ou, email=brinamc@aol.com, c=US Date: 2011.09.15 10:19:57 -05'00'

date

Gregory Brian Staples

site sUpervisor naMe

site sUpervisors signatUre

date

adMinistrator naMe

adMinistrator signatUre (iF diFFerent FroM the site sUpervisor)

date

Capella University | Capella tower | 225 soUth sixth street, ninth Floor Minneapolis, Mn 55402-3389 | 1.888.Capella (227.3552) | www.Capella.edU

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