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INTERN SH IP !ACKNOWLEDGE MENT!OF!
RISK!AND!CONSENT!FORM!
Section!I!!"
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Internship !Sit e :!
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ExL!Coordinator!or!Faculty!Sponsor:!
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Description!of!Internship!Activity:!
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Section!II!!
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I" understa n d " th a t" th e re " a re " c er ta in " d an g e rs ," h az a rd s" a n d " ris k s" a s so c ia te d " w ith " my" participa tio n " in " t h e" in t er n sh ip "
activity(s)" described" above." I" further" understand" that" all" risks" cannot" be" prevented." I" have" considered" the" risks"
associated" with" participating" in" this" internship" and" knowingly" and" voluntarily" assume" all" said" risks." Furthermore," I"
represent"that"I"am"physically"and"m e nta lly"capable"of"p articip atin g"in"th is"internship"and"that"I"am"capable"of"u sing "
the"equipment,"if"any,"asso ciate d"w ith"the"ac tiv ity .""
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On"behalf"of" myself,"and" my"family,"heirs,"assigns,"and" personal"representatives,"I" hereby"agree"to" indemnify,"hold"
harmless,"release"from"liability"and"waive"any"legal"action"against"Holyoke"Community"College,"its"governing"board,"
officers," agents" and" employees" (collectively," “the" Relea sed" Parties”)" for" any" person a l" in jury ," d eath ," or" property"
damage"I"may"suffer,"due" to"any" cause,"including"but" not"limited"to"the" negligence" of"the" Released" Parties," arising"out"
of"or"in"any"way" connected"to" my"participation"in " the" in te rn s hip " or" while"in " transit" to"or" from" where" the" a c tiv ity" is"
being"conducted.""
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I"represen t"th a t"I"am"covered "by "a d eq u a te "medical/h ea lth / a cc id e n t"in su r an c e "fo r"a n y"in ju ry "th a t"I"m a y "su ffe r"a t"th e "
internship "s ite ."In " th e" e ve n t"I" re q u ire" medical"services"due"to"an"injury"suffered"during"the"internship,"I"understand"and"
agree"that"Holyoke"Community"College"does"not"provide"m edical"services"or"medical"personnel"at"the"internship"site"
and"is"under"no"obligation"to"provide"transportation"for"me"to"obtain"medical"services.""
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I"unde rs ta n d "and"agree"th a t"this"d o c u m e n t"shall"be"con s tru e d "in"ac co rd a n c e "with"t h e"laws"of"the "Commonwea lth "of"
Massachusetts." If" any" term" or"provision"of"this" document" shall"be"held" invalid" or"unenforceable," the"remaining"terms"
and"provisions"shall"remain" in" full"force"and"effect."I"understand"that" by" signing" this"docum ent" I" am " representing"that" I"
have" read" and" understand" all" of" its" terms" and" conditions" and" that" I" fully" intend" to" be" bound" by" the" same." I" also"
understand"that"I"may"wish"to"consult"with"an"attorney"prior"to"signing"this"document."
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Student’s!Name:!
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! ! ! Student!ID:!
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Student’s!Signature:!____________ ____ ____ ____ ___ ____ ____ ___ ____ ____ !Date:!____ ____ ____ ____ !!!!"
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"
If"the"intern sh ip "p a rt icip a n t"is "u n d e r"1 8"y e a rs"o f "ag e,"in"signing"th i s"f o rm"in"the"sp a ce "p r o v id e d "you"are"ind ica t in g "th a t "
you,"as"parent"or"guardian"or"ward"of"the"above"named"person,"have"decided"to"allow"the"above"named"person"to"
participate"in"this"internship"placement"and"that"you"have"read"and"understand"the"information"provided"here."
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Parent/Guardian/Ward!Name:!
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Signature:________________________________ ________ _________ ________ __Date:_______ ________ !!!!!!!!!!!!!!!!!!!!!
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