Student Name:

Course:

Supervising Advisor:

Dates of Internship:

Faculty Supervisor:

During the dates listed above, I will be performing my student internship through the University of Maryland at College Park for the course shown above. I will be performing the internship to gain experiences that will assist me in my college education at the University. I will be undertaking the internship voluntarily and upon my own initiative, risk and responsibility.

In consideration for the permission given me by the Sponsoring Agency to obtain this experience, and in further consideration for the University of Maryland at College Park facilitating this arrangement, I (for myself, my heirs, executors, and administrators), release, discharge, and agree to indemnify the above named faculty, The University of Maryland at College Park, the Sponsoring Agency, and its agents and employees who have any role in facilitating my internship, acting officially or otherwise, from all claims on account of my death or on account of any injury to me or for damage to my property that may occur from any cause in connection with this internship, regardless of whether such death, injury, or damage is caused in whole or in part by the negligence of any of those indemnified.

I intend to indemnify the above named faculty, University of Maryland at College Park, the Sponsoring Agency, and all of its agents and employees who have facilitated my internship from the consequence of their own negligence, whether that negligence is the sole or concurring cause of the death, injury, or damage.

Signed this ______ day of _________ 19___

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Student Signature