Internship Permission Form
Name: ____________________________ T Number___________________________
FALL SPRING SUMMER YEAR _________
INSTRUCTOR of
RECORD SIGNATURE
Additional Information Required
Company Name ___________________________________________________
Company Address ___________________________________________________
State, Zip Code ___________________________________________________
Work Supervisor ___________________________________________________
Work Supervisor Telephone _______________________________
Internship Waiver of Liability
By going into functioning programs, rather than remaining in an on-campus classroom, students may expose themselves to
greater risks. For example, in many placements the host agency does not assume liability for injury or harm to the SUU students who
serve/work/volunteer in the program. Likewise employees of these agencies are not personally responsible for harm which may come
to SUU students in the course of their carrying out their services and educational activities. Southern Utah University similarly
assumes no liability for any such risk.
Given the supervision and limited case loads, SUU students are rarely exposed to even as much risk or harm as ordinary
human service workers. Nevertheless, the potential for transportation accidents, and some emotional or mental distress, is present.
SUU students are expected to exercise reasonable caution and to provide their own insurance to cover such harm, should it occur.
Students are also expected to conduct themselves according to the host agency’s policies and procedures and according to
the training which they receive, so as to further reduce risks of harm.
The intent of the practicum/cooperative/internship courses is to provide academic credit to SUU students who wish to gain
educationally meaningful field experiences. The student, as a legal adult, assumes primary responsibility for the consequences of
his/her conduct, for accidents, and for other harm or injury that may occur, recognizing that this learning format is more active and
involved than the traditional classroom setting.
By signing below I affirm that I have read this statement and have had my questions regarding risk and liability answered.
Also, by signing below, I assume all risks that may be inherent in and associated with the internship(s) in which I will be involved. I
also waive any claim against Southern Utah University, its agents and employees, for any harm, injury, damage or claim that may
result from my involvement in the practicum(s), cooperative(s) and internship(s) experience which does not occur as a direct result of
the University’s gross negligence. I further agree to indemnify the University and hold it and its agents and employees harmless from
any such harm, injury, damage or claim that affects me or someone else as a result of my involvement.
Student’s Signature & Date
