EmailMe Form - SDCCD Work Experience Application Spring 2024

WORK EXPERIENCE COURSE INFORMATION

For the satisfactory completion of all types of Work Experience Education, students may earn up to a total of 16 semester credit hours. Title 5, Section 55253.

View the SDCCD Class Schedule to determine the appropriate Work Experience course to take based on your placement, hours, and certificate/degree requirements.

Campus to Enroll in Work Experience: *

City College

Mesa College

Miramar College

Academic Term & Year: *

Student CSID #: *

MESA COLLEGE Work Experience Course: *

Work Experience credit is awarded based on 75 hours of paid work/internship or 60 hours of unpaid internship per unit the student is enrolled. By completing the WE Application and enrolling in WORK 270, you have acknowledged and agreed to fulfill all requirements and expectations of the Work Experience class as outlined by Title 5 and the Work Experience Student Handbook including minimum hours required per semester by unit. Failure to meet these requirements, specifically the minimum # of hours, may result in a failing grade assigned for your Work Experience course.

WE Credit & Hour Requirements - WE Hours Must Be Completed Within Course Dates:
1 unit - 60 Hours Unpaid | 75 Hours Paid
2 units - 120 Hours Unpaid | 150 Hours Paid
3 units - 180 Hours Unpaid | 225 Hours Paid
4 units - 240 Hours Unpaid | 300 Hours Paid

Have you been accepted into the Mesa College Small Business Virtual Incubator (SBVI) program for the Spring 2024 term? *

Yes

No

MIRAMAR COLLEGE Work Experience Course: *

Work Experience credit is awarded based on 75 hours of paid work/internship or 60 hours of unpaid internship per unit the student is enrolled. By completing the WE Application and enrolling in WORK 270, you have acknowledged and agreed to fulfill all requirements and expectations of the Work Experience class as outlined by Title 5 and the Work Experience Student Handbook including minimum hours required per semester by unit. Failure to meet these requirements, specifically the minimum # of hours, may result in a failing grade assigned for your Work Experience course.

WE Credit & Hour Requirements - WE Hours Must Be Completed Within Course Dates:
1 unit - 60 Hours Unpaid | 75 Hours Paid
2 units - 120 Hours Unpaid | 150 Hours Paid
3 units - 180 Hours Unpaid | 225 Hours Paid
4 units - 240 Hours Unpaid | 300 Hours Paid

CITY COLLEGE Work Experience Course: *

Work Experience credit is awarded based on 75 hours of paid work/internship or 60 hours of unpaid internship per unit the student is enrolled. By completing the WE Application and enrolling in WORK 270, you have acknowledged and agreed to fulfill all requirements and expectations of the Work Experience class as outlined by Title 5 and the Work Experience Student Handbook including minimum hours required per semester by unit. Failure to meet these requirements, specifically the minimum # of hours, may result in a failing grade assigned for your Work Experience course.

WE Credit & Hour Requirements - WE Hours Must Be Completed Within Course Dates:
1 unit - 60 Hours Unpaid | 75 Hours Paid
2 units - 120 Hours Unpaid | 150 Hours Paid
3 units - 180 Hours Unpaid | 225 Hours Paid
4 units - 240 Hours Unpaid | 300 Hours Paid

MESA COLLEGE SMALL BUSINESS VIRTUAL INCUBATOR (SBVI) PROGRAM AGREEMENT

The San Diego Mesa College Small Business Virtual Incubator (SBVI) program aims to assist students (Mentees) understand basic business management skills and helping them start, operate, and grow their company. This form serves as your agreement to the conditions of the SBVI program of which the Work Experience course is a component.

A student’s participation in the SBVI is voluntary and requires agreement to certain conditions. Please review the entire terms of the SBVI Agreement carefully before moving forward in this document and save a copy of them for your reference.

You must read and agree to the following terms and agreements in order to be approved to participate in the SBVI program:

Duration & Location of Business Mentoring
Types of Business Mentoring
SBVI Limitations
Work Experience Course Requirement
Reimbursement Requirements
Program Completion
Early Program Termination
Waiver of Liability for Business Mentoring

*Students may only receive funding from one grant source from Mesa College at a time. If accepted in both, students must choose to participate in the Small Business Virtual Incubator (SBVI) Program or the Mesa Impactship Program (MIP).

NOTE: If you have NOT BEEN ACCEPTED into the Mesa College Small Business Virtual Incubator (SBVI) Program, please answer 'No' to the previous question.

MESA COLLEGE SBVI STUDENTS ONLY - SBVI Agreement Authorization *

By checking this box, I acknowledge my participation, authorize the terms of the SBVI Agreement, and agree to fulfill all requirements and expectations of the Mesa College Small Business Virtual Incubator (SBVI) Program.

NOTE: If you have NOT BEEN ACCEPTED into the Mesa College Small Business Virtual Incubator (SBVI) Program, please answer 'No' to the previous question.

MESA IMPACTSHIP PROGRAM (MIP)

Get $$$ for Workforce Training! Interested in receiving a one-time $1000 payment (AKA stipend) or hourly compensation to offset expenses during your workplace training & enrollment in a Work Experience course? Check out and apply for the Mesa Impactship Program (MIP). Complete the intake form to check your eligibility!

*NOTE: Eligible students must be enrolled in a Work Experience or DCP course through Mesa College for the participating semester.

*Students may only receive funding from one grant source from Mesa College at a time. If accepted in both, students must choose to participate in the Mesa Impactship Program (MIP) or the Small Business Virtual Incubator (SBVI) Program.

STUDENT INFORMATION

Student Name *

First Last

Prior Work Experience Units Completed: *

Enter the # of college units you have previously earned based on enrollment in a Work Experience course(s) at any college.

Student Phone: *

### - ### - ####

Student Email: *

Declared Major: *

What is the primary reason for your enrollment in Work Experience this term? *

I want to develop my professional skills

I want to explore career opportunities through hands-on experience

I am earning college units to gain salary/pay advancement with current employer

Work Experience is required by my SDCCD academic program (Degree, Cert)

Other

Which SDCCD campus are you primarily enrolled? (Most classes taken/units earned) *

City College

Mesa College

Miramar College

This is my first semester enrolled at SDCCD

Are you seeking work experience credit for your own business? *

Yes

No

If Yes, please contact your assigned SDCCD campus Work Experience Coordinator for additional steps and approval.

City College - Nicole Vargas | nvargas@sdccd.edu
Mesa College - Shawn Fawcett | sfawcett@sdccd.edu
Miramar College - Kyoka Hashimoto | khashimoto@sdccd.edu

Are you an international student? *

Yes

No

If Yes, please contact your assigned SDCCD campus Work Experience Coordinator for additional steps and approval.

City College - Nicole Vargas | nvargas@sdccd.edu
Mesa College - Shawn Fawcett | sfawcett@sdccd.edu
Miramar College - Kyoka Hashimoto | khashimoto@sdccd.edu

Note: International students are required to attend the International Student Orientation, Employment Workshop, submit a CPT checklist, and update your I-20 in order to enroll in Work Experience.

Are you a Veteran student? *

Yes

No

If YES, please contact a Veteran Counselor and/or Veteran Services to understand how enrolling in a Work Experience course may impact your education plan and/or VA benefits.

Are you under 18 years of age? *

Yes

No

If Yes, please contact your assigned SDCCD campus Work Experience Coordinator for additional steps and approval.

City College - Nicole Vargas | nvargas@sdccd.edu
Mesa College - Shawn Fawcett | sfawcett@sdccd.edu
Miramar College - Kyoka Hashimoto | khashimoto@sdccd.edu

NOTE: A certified Work Permit will be required for students under 18 years of age.

Are you a current student enrolled at a 4-year university? *

SDSU

UCSD

Other

No, I am not currently enrolled at a 4-year university

If YES, please contact the Counseling or Advising Office at your institution to ensure that SDCCD Work Experience courses will satisfy your individual academic program requirements.

Are you a Child Development student - CHIL 270? *

Yes

No

CHILD DEVELOPMENT STUDENTS ONLY - By checking this box, I acknowledge and understand that I must be in compliance with new Child Development state regulations and I must be able to show proof of the following immunizations to my worksite BEFORE beginning lab hours.
• MMR - Measles
• Tdap - Pertussis
• Flu vaccination
• Covid-19 vaccination
• TB clearance, within the past 12 months *

I agree to comply with immunizations before beginning lab hours

NOTE: To avoid delays in completing your lab hours, please get your immunization record prior to the semester starting. Please contact your worksite placement for instructions on how to submit and meet requirements.

If you are NOT a Child Development student, please answer 'No' to the previous question.

WORK EXPERIENCE COMPANY / ORGANIZATION INFORMATION

Please provide some details on where you will be completing your work experience placement.

Company Name: *

Company Website / URL: *

Address: *

Worksite Address:

(if different than company address)

Site Supervisor Name: *

Assigned person at company to supervise & evaluate student during SDCCD Work Experience.

Site Supervisor Title: *

Site Supervisor Phone: *

### - ### - ####

Site Supervisor email: *

WORK EXPERIENCE POSITION INFORMATION - EMPLOYMENT / INTERNSHIP / VOLUNTEER

Please provide some details on how you will be completing your work experience placement.

WE Credit & Hour Requirements - WE Hours Must Be Completed Within Course Dates:
1 unit - 60 Hours Unpaid | 75 Hours Paid
2 units - 120 Hours Unpaid | 150 Hours Paid
3 units - 180 Hours Unpaid | 225 Hours Paid
4 units - 240 Hours Unpaid | 300 Hours Paid

Type of Work: *

Paid

Unpaid

Position Title: *

How long have you worked with this company? *

Note: If you are just starting work for this company, please indicate "0".

How long have you worked in this position? *

Note: If you are just starting work for this company, please indicate "0".

Main Duties/Assigned Responsibilities: *

Where will your Work Experience job/internship/volunteer position take place? *

Working onsite at the company

Working remotely from home

Both working onsite at the company AND remotely from home

Work Schedule (ie: 9:00am-12:00pm - Enter 0 (zero) if no shift hours for the day. Schedule can vary each week - Provide an anticipated schedule). Must meet minimum WE requirements required by units enrolled. *

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Average Total Hours Per Week
Shift Hours (am/pm)

MESA COLLEGE SBVI PLAN OF SCHEDULED HOURS

MESA COLLEGE SBVI STUDENTS ONLY - SBVI requires that you spend a minimum of 60 hours developing and launching or growing your business. Please estimate all the hours that you will spend working on your small business by the categories listed below and calculate the total hours.

*

	Orientation Meeting	Learning Agreement Meeting	Hours meeting with Esther	Hours meeting with Eddie	Mentoring Hours	Hours working on business development	Total Hours
Hours

For this work experience, will you:

Please provide some details on specific activities you will be completing your work experience placement.

Operate a company vehicle? *

Yes

No

Operate heavy equipment? *

Yes

No

(ie: forklift, bulldozer, press machinery)

Work with hazardous materials? *

Yes

No

Work with minors? *

Yes

No

Work in a private residence? *

Yes

No

If you answered YES to any of the above Risk Management questions, please provide additional details of your position responsibilities. Be specific about your work role. *

If you answered NO to all of the above questions, please type "n/a."

WORK EXPERIENCE REQUIRED FORMS

The following forms must be completed in order to submit a Work Experience Application and to receive approval to obtain an ADD code to enroll.

Work Experience Quiz - File Upload *

INSTRUCTIONS: View the Online Work Experience Orientation and upload completed Work Experience Orientation Quiz. Upon completion of the quiz, save as a PDF with a file name that includes your first and last name, WE Quiz, and term/year (ie: John Doe - WE Quiz - Spring 2019). Upload saved file into the online Work Experience Application. This quiz is required to receive an ADD code.

Online Work Experience Orientation

Work Experience Orientation Quiz

MESA COLLEGE SBVI REQUIRED FORMS

The following forms must be completed in order to participate in the SBVI Program.

Gender Equity, Sexual Harassment and Violence Training - File Upload *

This training includes an introduction to educational and workplace regulations and guidance regarding sexual harassment including how to recognize, report, and prevent sexual assault and harassment.

INSTRUCTIONS - MESA COLLEGE SBVI STUDENTS ONLY:

1. Self-Enroll in Training Course in Canvas
2. Complete the training. Organized into 3 modules: Key Concepts, Reporting and Response, Awareness and Prevention, you will find a series of short videos (about 2 mins. each) and supplemental handouts for review. Just hit the "next" button at the bottom right hand of the screen to move through the course content.
3. Submit documentation of completion. Print your grades to PDF and upload saved file into online Work Experience Application.

SBVI Supplier Intake Form - File Upload *

Complete this form to be setup for reimbursement of pre-approved expenses.

INSTRUCTIONS - MESA COLLEGE SBVI STUDENTS ONLY: Download the form below. Complete it, save file as PDF to your computer, and upload it here.

SDCCD Supplier Intake Form

Class Schedule / Unofficial Transcript - File Upload *

Complete this step to be setup for reimbursement of pre-approved expenses.

INSTRUCTIONS - MESA COLLEGE SBVI STUDENTS ONLY: Visit MySDCCD Portal to access a copy of your unofficial transcripts by term showing your classes for the current semester.

Follow this step by step tutorial to request unofficial transcripts via the mySDCCD portal.

21st CENTURY PROFESSIONAL SKILLS PRE-WORK EXPERIENCE SELF-EVALUATION

Work Experience is designed to help students develop professional skills through hands-on experience. Evaluate your current performance/ability of each of these 21st Century workplace skills prior to beginning your Work Experience. Ratings of student performance of each skill will be shared with your Work Experience Instructor and Site Supervisor to be discussed at the beginning and end of your Work Experience.

Evaluate your level for each of the following 21st Century workplace skills: *

	Excellent	Above Average	Competent	Unsatisfactory	Not Applicable
ADAPTABILITY: Open to new experiences by trying out different work environments, roles, and tasks.
ANALYSIS/SOLUTION MINDSET: Examines information and data using critical thinking skills and considers different ways to solve a problem.
COLLABORATION: Able to work with a diverse team, encourages using skills of all, and able to manage conflict.
COMMUNICATION: Articulates thoughts and ideas verbally and in writing in a professional manner, uses appropriate content, uses non-verbal communication to make things clear.
DIGITAL FLUENCY: Has a basic understanding of computer, online tools, hardware, and software to find data, information, answer questions, or help solve a problem.
ENTREPRENEURIAL MINDSET: Self-motivated, risk-taker, and seeks new knowledge, skills, ideas, and greater work responsibilities.
EMPATHY: Develops good relationships with people from diverse backgrounds and cultures by being a good listener, asking questions to understand what the other person is feeling, being honest, and mirroring nonverbal communication to build trust.
RESILIENCE: Sets priorities and goals, anticipates possible consequences, develops back-up plans, learns from feedback, and believes in personal growth.
SELF-AWARENESS: Knows own skills and strengths, works to improve weaknesses, maintains self-discipline, takes personal responsibility, and attempts to grow professional manner.
SOCIAL/DIVERSITY AWARENESS: Values diversity in the workplace, develops relationships with people of different backgrounds, and seeks out new ideas from others.

Comments & Feedback of Student Self-Evaluation:

Describe any area(s) and/or skill(s) that show great promise or need improvement.

STUDENT AUTHORIZATION

Please review and check each box below to acknowledge and agree to the policies and requirements of enrollment in a SDCCD Work Experience course. As a Work Experience student: *

I understand and approve that my Work Experience Instructor/Coordinator will be providing information about my Work Experience educational activities and enrollment to my Site Supervisor/company and my Site Supervisor/company will be providing information to my Work Experience Instructor/Coordinator concerning my educational job-related objectives and records.

I acknowledge and agree to fulfill all requirements and expectations of the Work Experience class I enroll in as outlined by Title 5 and the Work Experience Student Handbook (Minimum # of hours, required forms, evaluations, etc.).

Student Signature: *

Clear

Please use your computer mouse cursor or finger on a tablet to physically sign your name as you would for a wet signature.

UNABLE TO SIGN THE FORM?
If you have previously started the form and selected "Save & Resume Later," click on the "Clear/Delete" link in the bottom right corner of the signature field. This will clear the field and allow you to sign and submit the form.

Date Time *

MM / DD / YYYY

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