Fillable COVID- 19 INTERNSHIP WAIVER AND RELEASE PLE ASE (Suffolk University)

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COVID- 19 INTERNSHIP WAIVER AND RELEASE PLE ASE (Suffolk University)

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1
COVID-
19 INTERNSHIP WAIVER AND RELEASE
PLE
ASE READ THIS DOCUMENT COMPLETELY BEFORE SIGNING. THE EFFECT OF THIS DOCUMENT IS TO
RELEASE SUFFOLK UNIVERSITY FROM ANY LIABILITY RESULTING FROM YOUR PARTICIPATION IN A
COURSE, INTERNSHIP OR CLINICAL PROGRAM OUTSIDE OF MASSACHUSETTS.
I acknowledge that I have been advised by Suffolk University (“University”) that many academic classes
have been moved to online instruction due to concerns regarding COVID-19. I am knowingly electing to
perform my course and/ or internship/clinical hours at
__________________________________
(“Internship Site”) and accepting the potential risks posed by the in-person course and/or internship,
including the health risks associated with the COVID-19 pandemic.
To th
e extent my academic program requires internship/clinical hours, I acknowledge that the University
has encouraged all students to perform any required internship/clinical hours remotely. I further
understand that I have been provided an option to complete the hours necessary when the COVID-19
risk is abated to permit me to earn the academic competency and credit required of my academic
program. I also understand that the guidance from the CDC and the University may change, and I may be
required to adhere to those changes. However, I choose to complete the internship/clinical placement
at this time and I understand that my participation is completely voluntary and may include inherently
dangerous activities that expose me to certain damages and risks, including but not limited to all risk
associated with the COVID-19 virus such as serious illness, hospitalization or death, as well as risk that is
elevated for individuals with underlying medical conditions such as diabetes, lung disease and heart
disease.
I further understand that if I become ill or symptomatic or there are additional advisories or other
external restrictions on my participation in the internship/clinical experience, Suffolk or the Internship
Site may remove me from the Internship Site immediately. In consideration of being permitted to
participate in the internship/clinical placement at Internship Site, I do hereby release, waive and
discharge Suffolk University and its respective representatives, trustees, officers, employees, agents,
contractors and advisors (“Released Parties”) from any and all actions, damages, claims or demands
which I, my heirs, personal representatives, executers, administrators, or assigns may have against any
and all of the aforementioned for any and all personal injuries, accidents, or illnesses (including death),
known or unknown, which I have or may incur by participation in the above stated Event and for all
damages and loss to my property. The foregoing acknowledgement of risk and waiver of liability is
intended to be as broad and inclusive as is permitted by the law of the Commonwealth of
Massachusetts and that if any portion is held invalid, it is agreed that the balances shall,
notwithstanding, continue in full legal force and effect.
2
I, the undersigned, am at least 18 years of age. I have read this Acknowledgement of Risk and Waiver of
Liability and fully understand its terms. I acknowledge that I am signing this waiver freely and voluntarily
with full knowledge of its significance.
Name of
Participant (Printed): ____________________________________________________________
Signature of Participant: _________________________________________________________________
Date:_________________________________________________________________________________
If Participant is under the age of 18, his or her parent or legal guardian must also sign.
I, (printed name)
______________________
, am the parent or legal guardian of the participant who has
signed above. I have read and I understand the provisions of this document. I consent to the participant
taking part in the Activities described above, and I fully enter into and agree to the above Participant
Waiver and Release of Liability Form.
Signature of Parent (if Participant is less than 18 years of age):
__________________________________
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COVID- 19 INTERNSHIP WAIVER AND RELEASE PLE ASE (Suffolk University)

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Completed 1 February 2021

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