SENIOR NURSE PLACEMENT ACKNOWLEDGMENT FORM.PDF

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MARICOPA COUNTY 
SENIOR NURSING STUDENT PLACEMENT 
ACKNOWLEDGMENT FORM 
 
 
By signing this form, I, __________________________________________, understand and 
acknowledge the following: 
 
1. 
I will be participating in the Maricopa County Student Nurse Placement Program 
(“Program”).  
 
2. 
I will be placed with a local clinical employer and will be provided with educational hands-
on opportunities which will help to prepare me for real work experience.  
 
3. 
The Program is approximately [#] of weeks, for a minimum of [#] hours per week (not to 
exceed [#] hours per week), beginning [Date], and concluding [Date]. 
 
4. 
In order to successfully complete the Program, I am required to participate for the duration 
of the term of the Program. 
 
5. 
I have been informed that I will have a Preceptor assigned to me to provide one-on-one 
training and work activities oversight.   
 
6. 
I will receive a Stipend of $500 at the successful completion of my Program activity, paid 
to me by Maricopa County. 
 
7. 
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 those 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 actions against the County, its agents, representatives, officials, officers, 
directors, employees, volunteers, agencies, boards, committees, commissions, and 
departments (collectively, “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 site locations of the Program. The provisions of this paragraph 
shall survive the conclusion or termination of the Program or my dismissal from the 
Program. 
 
 
[Signature contained on the following page]

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I understand that by signing this document I am representing that I have read, accepted, and 
understood all of its terms and conditions and fully intend to be bound by the same. I also 
understand that the County will rely upon my execution of this document in agreeing to allow me 
to be placed, and participate, in the Program. Additionally, I understand that I may consult with an 
attorney prior to signing this document. 
 
 
Signature: _______________________________________ 
Date: __________________ 
 
Printed Name: ________________________________________________________________ 
 
Address: ____________________________________________________________________ 
 
Phone Number: _____________________________________ 
 
 
This section to be completed at the end of the Program activities and once received by the 
County, Stipend will be issued. 
 
I confirm that I have successfully completed my Student Placement activities. 
 
 
Signature: _______________________________________ 
Date: __________________ 
 
Confirmed By Student Advisor  
Name and Title: _______________________________________________________________ 
 
 
Signature: _______________________________________ 
Date: __________________