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Wilfrid Laurier University Waterloo Lutheran Seminary
December 5, 2016
Canadian Excellence


Waterloo Lutheran Seminary

Work/Education Placement Agreement Form

Mandatory Form fo all Internship, Practicum and SPE students

published: 2011 | Policy | Placement Agreement Form

Introduction: The Ontario Ministry of Training, Colleges and Universities (OMTCU) covers the cost of workers’ compensation and insurance for students, relieving the student, WLU and the host organization of the financial burden of paying premiums, but only for students who have completed this form as per the instructions below.  This form must be completed by any WLS/WLU student on non-paid work placements as per the Laurier Placement Procedure for Unpaid Training Participants.  Such placements include TH668H Practicum, TH681 Internship, TH562 CPE and SPE units/residencies.  Failure to deliver original form, completed in full, by the deadline, may result in financial or academic penalties.


1) Complete the form as follows:

Fill out all information.  For Post Secondary Institution write:  Waterloo Lutheran Seminary.  Name of contact person:  Sarina Wheeler.  Address: 75 University Ave W, Waterloo. Telephone: 519-884-0710.  Postal Code: N2L 3C5

B.1.  For Period of Agreement from and to, indicate the period of time in which you will be completing your placement (include an extra 2-3 weeks, in case you need extra time at the placement to make up for missed hours due to illness, etc.).  For Job Title write what your placement title is (e.g. ministry intern).
B.2.  For Hours of Training write what are the earliest and latest possible times of day you could be working at your placement (e.g. 9:00am - 3:30pm).
B.3.  For Schedule of Training, write all of the possible days that you could work at the placement


Inquire with the placement supervisor if the placement site has WSIB coverage for you.

If your placement has WSIB: Place a check mark in the C.1. box. For C.2., write 2011 on the line after "200_", and the number of work placement hours in the three-sided box beside it. Leave D blank.

If the placement site does not have WSIB coverage: Leave C blank.  Place a check mark in the D.1. box. For D.2., write the current on the line after "200_", and the number of work placement hours in the three-sided box beside it.

For Training Participant, student signs.  For Work Placement Employer, placement supervisor signs.  For Post-secondary Institution, leave blank.  Sarina Wheeler will sign there when the form is rdelivered.

2) Deliver the original, completed form to the Student Advisor at the Seminary Office before the first day of placement, or the first day of the term of registration, whichever date is first.

In the event it is necessary, OMTCU will then be able to apply the cost of workers’ compensation to the appropriate ministry account.  In case of an accident while on placement, please see this page for more information.

For information, please contact the Seminary Office at or 519-884-0710 ext. 3234.

Download: PDF (19k)    WLS_Work_Education_Placement_Agreement_Form.pdf

revised Jul 15/11

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