INTERNSHIP PROGRAM STUDENT ACKNOWLEDGMENT FORM.PDF
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Page 1 of 2 MARICOPA COUNTY INTERNSHIP PROGRAM ACKNOWLEDGMENT FORM By signing this form, I, __________________________________________, understand and acknowledge the following: 1. The Maricopa County Internship Program (“Program”) is approximately ______ weeks, for a minimum of ____ hours per week (not to exceed ____ hours per week), beginning ______________, 2020, and concluding ______________, 2020. 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 School for my participation in the Program, and Maricopa County (“County”) does not control eligibility for internship credit. 4. I have been notified of where I can view County policies. If I fail to comply with any rules, regulations, policies, or procedures of the County, then 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 it 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 County property, I will immediately notify my assigned Program supervisor. I understand and agree that the County is under no obligation to provide me with either medical services or transportation to obtain medical services. 7. I am responsible for obtaining a fingerprint clearance card in accordance with A.R.S. §§ 36- 594.01, 36-3008, 41-1964, and 46-141, as may be amended. I am responsible for providing a copy of the fingerprint clearance card to my school of record. I also acknowledge that I am only eligible for placement with the County if the results of the fingerprint clearance are clear and without incidents. 8. I am responsible for obtaining a Central Registry Background Check in accordance with A.R.S. § 8-804, as may be amended, prior to assignment to placement with the Program. I understand that I am responsible for providing a copy of the Central Registry Background Check to my school of record. I understand that the information contained in the Central Registry shall be used as a factor to determine placement qualifications. 9. I am responsible for obtaining three references and providing those references to the Program. 10. The County strives to maintain an environment free from discrimination and harassment. I understand that if at any time I feel I am being treated unprofessionally or inappropriately, then I have the right and responsibility to report this directly to the Maricopa County Department of Human Resources and my school’s designated coordinator who receives student concerns or complaints. Page 2 of 2 11. 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 either the Arizona State Retirement System or the County’s deferred compensation retirement plan as a result of my participation in the Program. 12. 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. 13. 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 either A.R.S. § 11-351, et seq. (Arizona laws governing county employee merit systems) or the Maricopa County Employee Merit System. 14. 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. 15. My school and the County may exchange personal information about me, including information from my educational records, in connection with my placement and participation in the Program. 16. 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. 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: ____________________________________________