Host Agreement Internship InformationIntern Name* First Last Intern Start Date* Proposed Schedule (subject to change)Mon. TimesTues. TimesWed. TimesThur. TimesFri. TimesSat. TimesSun. Times Brief job description (subject to change):*Business Contact InformationBusiness Name*Contact Name* Intern Placement Address (if different from business contact address) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberExtensionEmail* Direct Supervisor(s) Contact Info:Supervisor 1 Name* First Last Supervisor 1 PhoneSupervisor 1 Email* Has Supervisor 1 ever been convicted of a felony or misdemeanor?* No Yes Please note: answering yes to the above question does not automatically disqualify Supervisor from participating in this activity.Is Supervisor 1 over 18 years of age?* No Yes Supervisor 2 Name First Last Supervisor 2 PhoneSupervisor 2 Email Has Supervisor 2 ever been convicted of a felony or misdemeanor? No Yes Please note: this field is required if a Supervisor 2 is listed. Answering yes does not automatically disqualify Supervisor from participating in this activity.Is Supervisor 2 over 18 years of age? No Yes Career Mentor Hours: Please estimate the percent of the intern's time that will be overseen by each supervisor (total should equal 100). These numbers can be adjusted upon completion of internship.% of Intern's Supervision - Supervisor 1Please enter a value less than or equal to 100.% of Intern's Supervision - Supervisor 2Please enter a value less than or equal to 80.Note: Hours will be logged as volunteer hours in our system. We appreciate the time taken to orient and teach our interns about your career field.As a Host, I acknowledge:* 1. Santa Barbara County Education Office (SBCEO)/Partners in Education (Partners) will be the sole employer. 2. SBCEO/Partners agree to defend, indemnify, and hold harmless Host for any action brought by a participant of the internship program against Host as an employer, excluding actions brought due to Host or Host’s agents’ sole negligence or willful misconduct. 3. Workers' Compensation and liability insurance will be provided by SBCEO/Partners for up to $2,500 in coverage. 4. Any and all injury and compensation claims by the intern arising from this employment shall be handled by SBCEO/Partners. 5. SBCEO/Partners will be responsible for all intern bi-weekly payments. As a Host, I agree to provide the intern with:* 1. A defined work schedule for the 80 hour internship duration depending on scheduling needs of the business and intern, reserving the right to terminate an intern for just cause. 2. Structured and meaningful activities to support intern’s learning interests and objectives. 3. Appropriate daily work for the intern according to the prepared job description. 4. Job supervision as appropriate to each task. 5. A short orientation within intern’s first week on roles and responsibilities, the equipment needed to perform the tasks defined in the job description, and your expectations of the intern while at your business. 6. A space for the intern’s time card paperwork and belongings. 7. Open and available communication for questions from the intern. 8. Adequate time for intern evaluation and final paperwork. 9. Adequate breaks as required by law. I also agree to:* 1. Verify the intern’s timecard twice a month and submit a copy to SBCEO for payment. 2. Adhere to all federal and state regulations regarding employment child labor laws. 3. Complete an endpoint evaluation assessing the entire internship experience. 4. Submit payment for half of the total wages the intern(s) earn based on 14 training hours with Partners in Education and 80 internship hours at the Intern Host site, within 60 days of receiving the invoice. NOTE: Students earn minimum wage (currently $11/hour) for up to and no more than 80 hours of internship work and 14 hours of training (94 hours total). Intern Hosts contribute 50% of the total amount paid to their intern at the going-minimum wage rate. 5. Report to program staff any problems or difficulties that arise with the intern immediately and work with staff to identify constructive solutions that help to ensure successful completion of the internship. By typing my name in the box below and submitting this form, I hereby certify that the information provided herein is true and correct to the best of my knowledge, and I am able to legally enter into contracts for the business listed; and I acknowledge that I have read, understand, and agree to the terms contained herein.* This iframe contains the logic required to handle Ajax powered Gravity Forms. Contact us for more information: firstname.lastname@example.org or 805-964-4710 ext. 4413.