Nurse Aide, Nursing Refresher (RN),
EKG, and Dental Assistant
Page 4 of 7
November, 2018 – PreAdmission Application
WAIVER, RELEASE & INDEMNIFICATION AGREEMENT
I, , being of legal age, have voluntarily agreed to participate in an Externship (the
“Externship”) at:______________________________________________________________________ (the
“Facility”). In consideration for being permitted to participate in the Externship, I, acting individually & on behalf of my
children, parents, heirs, successors, assigns, personal representatives & estate, hereby agree as follows:
1. Release from Liability. I hereby release, acquit, & forever discharge the Facility, Collin College & their
respective employees, agents, servants, officers, directors, trustees, owners, affiliates & representatives (in their
official & individual capacities) (collectively, the “Released Parties”) from any & all liability whatsoever for any &
all damages, losses, or injuries, including death, to persons or property or both, including but not limited to any
claims, demands, actions, causes of action, damages, costs, expenses & attorneys’ fees, which arise out of, during, or
in connection with my participation in the Externship, including, but not limited to, any damages, losses, or injuries
to persons or property or both which may be sustained or suffered by me or any person in connection with my
association with, participation in, or travel to & from, & in conjunction with the Externship.
2. Indemnification. I hereby agree to indemnify, defend, & hold harmless the Released Parties from any &
all liability, loss or damages they or any of them incur or sustain as a result of any claims, demands, damages,
actions, causes of action, judgments, costs or expenses including attorneys’ fees, which result from, arise out of, or
relate to my participation in, or travel to & from, & in conjunction with, the Externship.
3. Severability. I agree that this Waiver, Release, & Indemnification Agreement is intended to be as broad &
inclusive as permitted by the laws of the State of Texas, & if any portion hereof is held invalid, it is agreed that the
balance hereof shall, notwithstanding, continue in full legal force & effect.
4. Representations. I release & discharge the Facility from all responsibility & liability for all injuries,
illnesses, medical bills, charges, or similar expenses I may incur while participating in the Externship.
5. No Employment. I understand & agree that my relationship with the Facility is not one of
employer/employee. None of the benefits provided by an employer to an employee, including but not limited to
minimum wage & overtime compensation, workers’ compensation insurance & unemployment insurance & other
employee benefits, shall be available from or through the Facility to me.
I HAVE CAREFULLY READ THIS WAIVER, RELEASE & INDEMNIFICATION AGREEMENT. I
FULLY UNDERSTAND ITS CONTENTS & SIGN IT OF MY OWN FREE WILL. I UNDERSTAND
THAT BY SIGNING THIS AGREEMENT I AM GIVING UP VALUABLE LEGAL RIGHTS.
In case of emergency, please notify (NAME)
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