CREIGHTON STUDENT ACKNOWLEDGEMENT FORM.DOCX

MARICOPA COUNTY INTERNSHIP PROGRAM
ACKNOWLEDGMENT FORM
By signing this form I, __________________________________________, acknowledge the following:
1. The Externship Program with Public Defense Services (the “Program”) is approximately ______ weeks, for a
minimum of ____ hours per week (not to exceed ____ hours per week), beginning ______________, 20___
and concluding ______________, 20___.
2. In order to successfully complete the Program, I am required to participate for the duration of the term of the
Program.
3. It is my responsibility to seek academic credit from my college for my participation in the Program. The
County does not control eligibility for externship credit.
4. I have been notified of where I can view Maricopa County policies. If I fail to comply with any rules,
regulations, policies, or procedures of the County, such failure may result in disciplinary action, up to and
including dismissal from the Program.
5. Transportation to and from the Program is my sole responsibility, and shall not be the responsibility of the
County.
6. I am responsible for maintaining my own health insurance throughout the entire term of my participation in
the Program. In the event I am injured while on Maricopa County property, I will immediately notify my
assigned Program supervisor. I understand and agree that Maricopa County is under no obligation to provide
me medical services or transportation to obtain medical services.
7. I understand I have the responsibility to act professionally and appropriately at all times while participating in
the Program. If at any time I feel I am being treated unprofessionally or inappropriately, I have the right and
responsibility to report this directly to the Department of Human Resources.
8. I am not an employee of the County and therefore I will not be entitled any benefits normally associated with
employment with the County, such as, but not limited to, wellness programs, paid leave accrual, commuter
benefits, and health, behavioral health, pharmacy, vision, dental, life, and short term disability insurance
programs. Also, I will not be entitled to enroll in the Arizona State Retirement System or the County’s
deferred compensation retirement plan as a result of my participation in the Program.
9. I am not entitled to any wages from the County and I will not be eligible for unemployment compensation
benefits when my externship ends, even if the County terminates my services.
10. My externship is at will, terminable at any time, and participation in or completion of the Program does not
entitle me to a job with the County or any of the protections afforded by A.R.S. § 11-351 et seq. (Arizona
laws governing county employee merit systems) or the Maricopa County Employee Merit System.
11. I understand that I may be exposed to confidential information while participating in the Program and I agree
to respect the confidential nature of all information whether in hardcopy or electronic form which may be
revealed to me in any manner. I also agree not to remove such information via copies or by other recording
means from County work locations.
12. My school and Maricopa County may exchange personal information about me, including information from
my educational records, in connection with my placement and participation in the Program.

13. I understand that there are certain dangers, hazards and risks associated with my participation in the Program.
I further understand that all risks cannot be prevented. I have considered the risks associated with
participating in the Program and knowingly and voluntarily assume all said risks. 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 Maricopa County, its governing board, officers, agents and
employees (collectively, “the Released Parties”) for any personal injury, death, 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 Program or while in transit to or from the site location(s) of
the Program.
I understand that by signing this document 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
consult with an attorney prior to signing this document.
Signature: _______________________________________________ Date: ____________________
Print Name: ______________________________________________