STUDENT WAIVER FORM REGARDING COVID-19.PDF

MARICOPA COUNTY INTERNSHIP PROGRAM INFORMED CONSENT AND WAIVER FORM 
REGARDING COVID-19 
 
By signing this form, I, ________________________, I understand and acknowledge the 
following: 
1. 
By participating in the Maricopa County Internship Program (“Program”) and in going to 
premises associated with the Program (“Premises”) an inherent risk of exposure to 
COVID-19 exists from people who are or have been present, including sickness and 
possible death, and that all such risks cannot be prevented.   
2. 
By participating in the Program and entering the Premises, I am voluntarily assuming all 
risks related to exposure to the coronavirus or other public health risk.   
3. 
I agree not to hold Maricopa County and its agents, representatives, officials, officers, 
directors, employees, volunteers, agencies, boards, committees, commissions, and 
departments liable for any illness or injury I may sustain in connection with or arising 
out of my participation in the Program and use of the Premises. 
4. 
I agree to take certain precautions, which will help keep everyone safer from exposure, 
sickness and possible death, including, but not limited to:  A.) only entering the Premises 
if I do not have a fever or other symptoms and do not believe I have been exposed to 
COVID-19; B.) washing my hands or using alcohol-based hand sanitizer both before and 
after I enter the Premises; C.) adhering to the face masks/coverings and safe distancing 
precautions that have been set up in the Premises; D.) keeping a distance of at least 6 
feet and having no physical contact with other individuals in the Premises; E.) trying not 
to touch my face or eyes with my hands, and, if I do, immediately washing or sanitizing 
my hands; and F.) if I believe I have been exposed to other people who are infected with 
the coronavirus, I will immediately notify the School and the Program Internship 
Coordinator if I test positive for COVID and I will cease from entering the Premises and 
will not resume visits until I have either been cleared by a medical provider or laboratory 
as not having COVID-19 or completed a self-quarantine of no less than 14 days.   
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:  ________________________________