Pirate Apprentice Days Application
SU Pirate Apprentice Days
Release and Indemnity Agreement
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ATTENTION STUDENTS: PLEASE COMPLETE THE BOTTOM PORTION ONLY! |
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This section will be completed by Career Services
Student's Name: _________________________________________________________________ |
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During the date(s) shown above, I will be job shadowing at the company named above. I understand that I will not be paid for this work and that no employer-employee relationship will exist between me and the company. Instead, I will be performing this work to gain experience that will help me in my college education at Southwestern University and in my career. I will be at this work site voluntarily and upon my own initiative, risk and responsibility.
In consideration for the permission extended to me by the company to obtain this experience, and in further consideration for Southwestern University facilitating this arrangement, I, for myself, my heirs, executors, and administrators, release, discharge, and agree to indemnify both the company and Southwestern University and all of their agents and employees from any claims on account of my death or on account of an injury to me or for damage to my property which may occur from any cause during this time, 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 company, Southwestern University, and all of thier agents and employees from the consequences of their own negligence, whether that negligence is the sole or a concurring cause of the death, injury, or damage.
Signed this the Day of , 2010.
Typed Student Name: Student ID #:
SU Box #:
Campus Phone: Cell Phone:
Winter Break Phone:
Winter Break Mailing Address:
I have read this "RIA" and program guidelines and agree to abide by all information pertaining to the SU Pirate Apprentice Day Program.
Signed: _____________________________________________________________ Date: ____________
SU Pirate Apprentice Days
Student Registration Form (Page 2)
Name:
Current Address:
Campus Phone: Cell Phone: Email:
Major(s): Minor(s):
Why are you interested in this opportunity? What are your expectations?
(Please limit answer to what is visible in box)
What are your career dreams? What career(s) would you like to learn more about?
(Please limit answer to what is visible in box)
Specify any companies and/or organizations that you may be interested in:
(Career Services cannot guarantee that you will be matched with any of the organizations you list. We encourage you to broaden your scope of employers to include those in the government and non-profit areas.)
Please list in order the city and areas you are willing and able to travel to for the job shadowing (ex. Boston, MA, Greater Houston Area, South Fort Worth):
1.
2.
3.
4.
5.
Specify date(s) you are available during winter break: (special conditions may apply)
Monday, Jan. 4 Tuesday, Jan. 5 Wednesday, Jan. 6 Thursday, Jan. 7 Friday, Jan. 8
Check Length: 1/2 Day Full day More than one day Full week
If checked 1/2 day, please check one of the following: Morning Afternoon Either
Additional Comments:
Please complete and return this form by 5:00 pm on Friday, November 13, 2009 to Career Services. Remember, by turning in this form you have made a commitement to participate in the job shadowing program. If you need to cancel you must notify the employer AND Career Services within 48 hours of your shadowing date. Thank you for your participation in this rewarding program!
