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Exhibit A: 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.").

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

  1. This agreement applies to the following programs:______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________.

  2. 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. 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. 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. Further, the Facility shall provide the Institution with written reasons for its non-acceptance of student(s) or faculty.

  3. 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. 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.

  4. If preceptors are used as an integral part of the A.L.E., 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 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.

  5. Institution students and faculty members have executed the following documents:

    Check the applicable documents that have executed

    1. ___ Authorization for Release of Records and Information
    2. ___ Applied Learning Experience Agreement
    3. ___ Agreement Concerning Faculty Supervision of an Applied Learning Experience

    While a sample copy of each document is attached hereto and hereby incorporated by reference, copies of each executed document are available upon request:

  6. 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: _______________________________________________________

    2. 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.

  7. It is understood and agreed that all terms and conditions forming a part of the Memorandum of Understanding by and between _________________________________________ and the Board of Regents of the University System of Georgia, by and on behalf of ___________________________ dated ___________________ 199__, are hereby incorporated by reference and shall remain in full force and effect during the term of this Agreement.

  8. Unless sooner canceled as provided herein, the term of this agreement shall be for a period of three (3) years, 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. may complete the A.L.E. 
NAME OF INSTITUTION


__________________________________________
Signature

Name:_____________________________________
      (Please Print)

Title:____________________________________

Date: ____________________________________                             


NAME OF FACILITY


__________________________________________
Signature

Name:_____________________________________
      (Please Print)

Title:____________________________________

Date: ____________________________________

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