Contact Information Sheet

About You

Name

Address

City/St/Zip

Email

PRIMARY ( )

Rcv/Send Text? Yes No

Backup ( )

Emergency Contact

Name

Relation

Phone ( )

About Your Externship Site

Facility

City/State

Where You Will Be Living During Your Externship Same as Above

Name

Address Home Phone ( )

City, St, Zip Mobile Phone ( )

Email

Externship Orientation Receipt

I have received access to the following information via www.keiseruniversity.org:

Culinary Externship Guide (Pending)

Syllabus

Externship Agreement

Externship Calendar

Weekly Summary Sheets

Performance Appraisals

Site Appraisal

I understand that in order to start my externship, I must complete and turn in the following before I begin:

Signed Externship Orientation Receipt

Signed Evidence of Understanding

Contact Info Sheet

Externship Application Consent Form

Health Insurance Notification Form

Attendance Policy Notification Form

Proof of Insurance

Your Current Résumé

Signed Externship Agreement

Your Supervisor’s Résumé

Completed Externship Clearance Form

Once I begin my externship, I realize that I must complete the following assignments in accordance with the schedule I have been given:

Submit time sheets and all other required documents by fax or email every Sunday evening

by 11:59 pm, EST.

Have your Chef Supervisor complete and fax four (4) performance appraisals at the end of

the fourth, eighth, twelfth and sixteenth weeks. You are responsible for ensuring they are

delivered to the Externship Coordinator.

Submit weekly assignments – ON TIME – each week.

Turn in a completed Portfolio (per specified criteria) no later than the Friday of the final

week - as indicated on your Externship Calendar.

Signature Print Name Date

1. In the address line of your web browser, type the following address:

www.keiseruniversity.org 2. Click on Login

3. Enter the Username: Externship

Enter the Password: ChefPam All usernames and passwords are case sensitive

4. Click Go To Class.

Keiser University Culinary Arts Externship Application

Consent Form (Effective May 31, 2011)

Please read each statement, print name on each line, sign and date at the bottom of the page.

Keiser University and the respective sites have agreed that these placements are final and students should not request a change from either the site or Keiser University. I, _______________________________________, understand that Keiser University is not responsible for my transportation, room, or board as it relates to my Externship site. It is my responsibility to make appropriate arrangements in order that I may be at the Externship Site on the first designated day of my externship. I, ________________________________________, do hereby give consent to Keiser University’s Culinary Arts Department Faculty to release information in the form of a Professional Reference to any externship site for which I request. I, ________________________________________, do hereby give consent to Keiser University’s Culinary Arts Department Externship Coordinator or Program Director/Coordinator to release my name, address, and phone number to the Externship Site(s) to which I have applied. I, ________________________________________, do hereby give consent to Keiser University’s Culinary Arts Department Externship Coordinator or Program Director/Coordinator to communicate with my supervisor (s) at my externship site to ensure accurate appraisal of my externship performance. Student ID ___________________________________ Student Name (print) ______________________________________________________ Student Signature _________________________________________________________ Date ________________________

Keiser University Culinary Arts Department

Health Insurance Notification

(Effective May 31, 2011)

In adhering to the Keiser University policy regarding health insurance, the Culinary Arts Program will require that all students enrolled in the program, (current and future) obtain health insurance coverage, prior to attending their Culinary Arts Externship. Any student that does not abide by this requirement will not be permitted to advance to their Culinary Arts Externship. Student health insurance is available through independent providers, as well as through the Student Services Department. I have read the above information and: (please check one)

______ I have health insurance. (Must provide proof)

______ I will purchase health insurance prior to the start of my Culinary Arts Externship. (Must provide proof)

Student ID ___________________________________ Student Name (print) ______________________________________________________ Student Signature _________________________________________________________ Date ________________________

Keiser University

Externship Attendance Policy Acknowledgement Form (Effective November 21, 2011)

Your Weekly Sheets are your attendance. If they are not received on time, you are marked absent for a 1-week period. According to the new policy - which is a Federal Mandate - if you fail to submit hours for a fourteen-day period, you will be dropped from school. The verbiage is listed below:

Pursuant to the Code of Federal Regulations Title 34, Part 668:

The student has a responsibility to notify the University of his/her intent to withdraw and indicate in writing the date of the withdrawal and the date he/she plans to return. This should be directed to the Dean of the campus via letter or email and must be submitted prior to the date of return to the next term.

The student will be withdrawn from the University if the notification is not received prior to the next term.

A student that withdraws and does not notify the University of their intent to return must be withdrawn within 14 days of the last date of attendance.

In addition, any student who has not attended class within 14 days must be withdrawn.

I understand that failure to submit my Weekly Summary Sheets for a period of fourteen (14) days or more will result in an automatic withdrawal from Keiser University.

I understand that if I fail to submit attendance or am a few days late for even a single week, it could result in an automatic withdrawal from Keiser University.

Student Name (print) _________________________________________ Student ID_______________

Student Signature ____________________________________________ Date ___________________