Internship Contract - Final

Your First Workflow Section

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Section A: Student Information

This form is to be completed by the student in collaboration with their HU advising professor.
It is highly recommended that you meet in person with the advising professor and present an internship job description before you begin this form.
Failure to do so may result in contract rejection by the faculty advisor.

Student name:*

First Name

Last Name

Student ID:*

Email*

Phone*

Classification during study: *

FR SO JR SR PG

Major 1*

Minor 1 (if applicable)

Major 2 (if applicable)

Minor 2 (if applicable)

Concentration (if applicable)

Section B: International Student Notification

To be completed by the student.

Are you an international student: *

Yes No

Please note: A new I-20, is required to maintain your F1 status. Failure to obtain a new I-20 could result in loss of your visa and you could be sent back to your home country.

You may not start the internship until you have an updated I-20 with the approval showing on the 2^nd page of the I-20.

Please provide the following CPT(Curricular Practical Training) information with the assistance of your advisor to aid the Huntington University Designated School Official (DSO), Sarah Rickerd in the creation of a new I-20. Please contact Sarah Rickerd in the Student Life Office if you have any questions.

Academic Course Title*

MUST BE VERIFIED BY ADVISOR

Course Number*

MUST BE VERIFIED BY ADVISOR

Anticipated Graduation Date*

MUST BE VERIFIED BY ADVISOR

How is this course, internship, or practicum related to your curriculum? Use your course description or syllabus to complete.*

Sign below stating you have read the above information and understand the expectations.*

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Designated School Official Approval

Sarah Rickerd's Signature:

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Section C: Course Information

To be completed by the student in collaboration with the advising faculty member.

Department: (Which department should your experience be counted in?)*

Semester:*

Year:*

Course Number:

MUST BE VERIFIED BY ADVISOR

Supervising HU professor:*

First Name

Last Name

Supervising HU professor’s email:*

Is your advisor your supervising HU professor?*

Yes No

Advisor:*

First Name

Last Name

Advisor’s email:*

Course type and credit hours: *

MUST BE VERIFIED BY ADVISOR

Section D: Internship or Practicum Information

To be completed by the student.

Company, organization, or department:*

For example, Parkview Hospital, Star Financial Bank, or HU History Department

Company Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Site supervisor:*

First Name

Last Name

Site supervisor’s title:*

For example, Director of Finance, HR Director, or Prof. John Doe

Site supervisor’s email:*

Supervisor’s phone:*

Start date of experience:*

End date of experience:*

Compensation: *

Hours per week:*

Total hours for the experience:*

Note: 40 hours of work =1 internship credit hour. 30 hours of work = 1 practicum credit hour.

Internship job description

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Enter work assignments or day-to-day projects if you do not have a job description*

25 minimum characters

List 2 skills you have learned in your classroom that you hope to use in this experience.*

25 minimum characters

Name three goals for this experience. What do you hope to learn?*

25 minimum characters

Section E: Student Release

Please read and sign in agreement to the statement below:

I, the above named student, am 18 years of age or older, and am participating in the experience listed in this contract of my own free will. I acknowledge that within the course and scope of my activities as described in this contract, I may be exposed to hazards or risks that may result in my illness, personal injury, or death and I understand and appreciate the nature of such hazards and risks. In consideration of being permitted to participate in the Activity, I hereby accept all risk to my health, including any injury or death, and property that may occur while I am acting within the course and scope of the Activity as an intern or otherwise participating in the Activity. To the best of my knowledge, I can fully participate in this Activity.

I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Huntington University, its Board of Trustees, their officers, servants, agents, and employees (hereinafter referred to as RELEASEES), from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while interning or otherwise participating in the Activity, or while in, on or upon the premises where the Activity is being conducted or in transportation to and from said premises.

I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS RELEASEES from any loss, liability, damage or costs, including court costs and attorneys’ fees they may incur due to my participation in said Activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise.

It is my express intent that this Student Release Form shall bind the members of my family and spouse (if any), if I am alive, and my heirs, assigns and personal representative, if I am not alive, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE above named RELEASEES.

I further understand and acknowledge that HU is not an insurer of my personal safety or property. I UNDERSTAND THAT THE UNIVERSITY WILL NOT BE RESPONSIBLE FOR ANY MEDICAL COSTS ASSOCIATED WITH ANY INJURY I MAY SUSTAIN. I also understand that I should and am urged by HU to obtain adequate health and accident insurance to cover any personal injury to myself that may be sustained during the Activity or the transportation to and from said Activity.

I further agree to become familiar with the rules and regulations of HU and not to violate said rules or any directive or instruction made by the person or persons in charge of said Activity and that I will further assume the complete risk of any activity done in violation of any rule or directive or instruction.

IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Student Release Form, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same. I understand this Student Release Form will be construed in accordance with the laws of the State of Indiana.

Student's Signature:*

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Date:*

Section F: Criteria for Academic Evaluation

To be completed by the supervising HU professor in collaboration with the student.

Faculty Determined Learning objectives (list below):*

25 minimum characters

Assessment criteria (check all that apply):*

Student self-evaluation (Required) Site supervisor evaluation (Required) Log of daily/weekly experiences Copies of reports or projects assigned Follow-up with periodic visits Final paper Final oral debriefing Other

Type "Other" Assessment Criteria:

Would you like to add any comments or request any edits to the contract?

Yes No

Comment :

Supervising HU professor's signature below approving this experience for credit*

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Date: