2009-2010 Internship Registration Form

*Note: Please fill this form out completely and appropriately, as it will be used for official records. 


Student Information

Last Name:     First Name:    
D#:     Slayter Box #:   
email   
Phone #:   
Major:
Minor:
Class Year:  2010    2011    2012    2013  
Gender:  Male    Female  

Internship Information

The internship that you are doing is a(n):
 Catalog Internship   
 Independently Arranged Internship  
Catalog Number (If a catalog internship):   
When will your internship be completed?
 Fall 09  
 Winter Break 09 -10  
 Spring 10  
 Summer 10  
Name of Organization:    
Industry/Career Field:
Name of Supervisor:    
Supervisor's Title:   
Street Address:   
City, State, Zip:   
Supervisor Email:   
Phone Number:   
Website:   

Student Release

Whereas, the undersigned, _______________________ (student name) hereafter called "Student" desires to have the privilege of participation in the Denison Internship Program.

Therefore, it is agreed as follows: That in consideration of Denison University, Granville, Ohio, allowing, subject to its rules and regulations, __________________________ (student name), the undersigned on behalf of themselves and guardian or parent, if under 18, do hereby voluntarily assume all risks of accident or damage to the person or property of the student participating in said project and do hereby release and discharge Denison University, and its agents, from every claim, liability or demand of any kind however caused for or on account of the personal injury or damage of any kind sustained by said student while participating in said project.

The student further promises to indemnify and forever save harmless Denison University or its agents from every claim, liability or demand of any kind however caused, for or on account of the personal injury or damage of any kind sustained by said student, if enrolled in said project.

In the event of an accident, the student’s medical coverage, either personal coverage or the student medical plan, should respond. Additionally if a claim is made against the student participant of a personal liability nature, personal homeowners and/or renters insurance should respond.

It is expressly understood that if said student is permitted to participate in said project that such participation is subject to the rules and regulations of Denison University and that said student is subject to the controls exercised by the professors or persons in charge of said project.

Student's signature   
Today's Date:    

Emergency Information

You are covered by:
 Denison University Student Medical Plan  
 Private Insurance  
Company Name:     Address:   
Policy Number:     ID Number:    
In case of emergency, illness requiring an operation, or if the parents cannot be quickly reached, will you leave the decision to the physician and the professors-in charge?
 Yes  
 No  
If the answer is "no", kindly explain:

Parents may be reached at the following telephone numbers: 

Parent(s) Name(s)   
Home Phone:     Business Phone:    
Home Phone:     Business Phone:    
Other Close Relative Name:   
Home Phone:    

Acknowledgment

I understand that receiving Transcript Notation requires the successful completion of the following:

Student:

  • REGISTER your internship with Career Services by using this on-line form/Once an internship is secured. 
  • COMPLETE the minimum of 100 hours.
  • COMPLETE a Self-Evaluation on-line/Deadline September 1, 2009

Employer:

  • Independently Arranged on-line form (if an independently arranged internship)/Once an internship is secured.
  • On-line Evaluation/Deadline September 1, 2009
Failure to complete the requirements by all assigned deadlines will prevent Transcript Notation.