INTERNSHIP PROGRAM STUDENT ACKNOWLEDGMENT FORM.PDF

MARICOPA COUNTY INTERNSHIP PROGRAM
ACKNOWLEDGMENT FORM
By signing this form I, __________________________________________, acknowledge the following:
1. The Maricopa County Internship Program (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 internship 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 internship ends, even if the County terminates my services.
10. My internship 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: ______________________________________________