Exhibit C: Institution and Facility Applied Learning Experience Agreement

This is an agreement on the part of NAME OF FACILITY (hereinafter referred to as the "Facility") and the Board of Regents of the University System of Georgia on behalf of NAME OF INSTITUTION (hereinafter referred to as the "Institution").

WHEREAS, the Institution desires to obtain and the Facility desires to provide high quality applied learning experiences for the Institution's students, while at the same time enhancing the resources available to the Facility for the providing of care to its clients and patients, through the operation of an applied learning experience (hereinafter referred to as the "A.L.E. Agreement").

NOW THEREFORE, in consideration of the mutual covenants and promises contained herein, the parties agree as follows:

This agreement applies to the following programs:
1. The Institution will use its best efforts to provide the Facility with information concerning the number of students, students' department/college, course of instruction, and dates of participation, thirty (30) days prior to the commencement of the A.L.E. Agreement When available, student names shall be provided prior to the students' participation at the Facility. The Institution shall provide the number of faculty participants and the faculty department/college at least fifteen (15) days prior to the commencement of the A.L.E. Agreement. Although the Facility may decline the acceptance of student(s) or faculty, it will promptly notify the Institution of all students or faculty who are accepted into the A.L.E. Agreement Further, the Facility shall provide the Institution with written reasons for its non-acceptance of student(s) or faculty.
2. Upon receipt of the above information identified above in paragraph 1., the Facility shall designate the classroom or conference space, Facility personnel, and other facilities or equipment appropriate for the A.L.E. Agreement and agrees to inform the Institution of same. The Facility agrees to use its best efforts to provide additional facilities, equipment and personnel as reasonably requested by the Institution. The availability of additional facilities, equipment and personnel will be subject to availability, prior requests for those resources, and the Facility's obligations regarding operation of the Facility.
3. If preceptors are used as an integral part of the A.L.E. Agreement, evaluation(s) by the Preceptor(s) will contribute to the evaluation of participating student practice competency. The Preceptors will have appropriate licenses and degrees. The following are specific Preceptor requirements:
  
  program preceptor
4. Institution students and faculty members have executed the following documents. While a sample copy of each document is attached hereto and hereby incorporated by reference, copies of each executed document are available upon request:
  1. Authorization for Release of Records and Information
  2. Applied Learning Experience Agreement
  3. Agreement Concerning Faculty Supervision of an Applied Learning Experience
The following individuals will respectively serve as the faculty/staff representative(s) for the Institution and the contact person for the Facility:
1. Institution Faculty/Staff Representative(s):

Program:		_________________________________________
Name(s):		_________________________________________
Address:		_________________________________________ _________________________________________
Telephone Number:		_________________________________________
Fax Number:		_________________________________________

B. Facility Contact Person:

Program:		_________________________________________
Name(s):		_________________________________________
Address:		_________________________________________ _________________________________________
Telephone Number:		_________________________________________
Fax Number:		_________________________________________

In the event that an Institution or Facility contact person changes, the Institution or the Facility, as appropriate, hereby agrees to promptly notify the other party of such change.

It is understood and agreed that all terms and conditions forming a part of the Memorandum of Understanding by and between the Georgia Hospital Association and the Board of Regents of the University System of Georgia last dated: , as amended, are hereby incorporated by reference and shall remain in full force and effect during the period of this A.L.E Agreement.
Unless sooner canceled as provided herein, the term of this agreement shall be for a period of one (1) year, commencing on , and ending on . This agreement may be renewed or amended at any time by mutual written consent of the parties. It may also be canceled at any time by either party upon not less than ninety (90) days written notice, but any students currently in an A.L.E. Agreement may complete the A.L.E. Agreement

NAME OF INSTITUTION

Signature: ________________________________________

Name: ________________________________________
Please Print

Title: ________________________________________

Date: ________________________________________

NAME OF FACILITY

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Exhibit C: Institution and Facility Applied Learning Experience Agreement