Free agency agreement 40Free agency agreement 40Free agency agreement 40
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NEW JERSEY MODEL EMPLOYER/AGENCY AGREEMENT
FOR UNPAID, SCHOOL-SPONSORED STRUCTURED LEARNING EXPERIENCES
(N.J.A.C. 12:56-18, School-to-Work Program and N.J.A.C. 6A: 6A:19-4, Structured Learning Experiences)

PART I: STUDENT INFORMATION
Student Name: ___________________________________ Student#: ___________________ Date of Birth: _______
Student Address: _________________________________ City: ____________________State: _____ Zip: _______
SLE Teacher Supervisor: ______________________________ Student Emergency Phone #: ___________________
EMERGENCY CONTACT INFO: Name:_______________________________ Relation:____________________
Business/Agency Name:_____________________________________________ Employer ID #:__________________
SLE Site Address:___________________________________ City: ___________________ State: ____ Zip: _______
SLE Site Telephone: ____________________ Fax:_________________ E-mail: ______________________________
SLE Start Date: __________ End Date: ___________Work Site Me