University of Northern Virginia

7535 Little River Turnpike, #103 Annandale, VA 22003

Career Services Office

Phone: (703) 941-0949 Fax: (703) 941-0893

Internship/Cooperative Education Consent and Release Form

Student Name: Degree: Student ID#: Major:

The following Agreement is designed to protect all participants in the University of Northern Virginias internship/Co-Op education programs, including students, faculty members, the University of Northern Virginia and the agencies and individuals cooperating with the University. You, as the student, should sign this form to indicate agreement and permission to participate. I understand that participation in the Co-Op program is entirely voluntary and that any such program involves some element of risk. I agree that in consideration of the University of Northern Virginia sponsoring this activity and permitting me to participate, I will indemnify, defend and hold harmless the University of Northern Virginia, its officers, agents, employees, successors and assigns from liability for any and all claims, demands, rights or causes of action, present or future, resulting from or arising out of any travel or activity conducted by or under the auspices of this internship program. I also understand that the University of Northern Virginia has the right to cancel my participation in this program if I violate any academic rules, immigration laws or any other violation under the U.S. laws. I also confirm the fact that I received a copy of the school Co-Op guide lines and I will follow all the rules in that document and any other regulation later imposed by U.S. Immigration and Customs Enforcement (ICE). I also confirm that I will follow any other rules that the school might impose on the Co-Op program in order to improve the program and I will have to maintain a GPA of 3.0, keep my attendance rate not below 75% in all my classes and maintain S grade in all ORTN 590 practicum that I will register in order to continue with my CPT work authorization. I also understand that failing to secure S grade can cause termination of my CPT and denial of my application for vacation. I understand that the University requires that all students be covered by appropriate accident and medical insurance and that the student be financially responsible for such expenses.

Note: International students in F-1 visa status must obtain authorization from the Career Services Office before being able to work in the United States.

MY SIGNATURE BELOW VERIFIES THAT I AM COVERED BY THE REQUIRED INSURANCE. ALSO, I HAVE READ AND UNDERSTAND THE ABOVE PROVISIONS AND AGREE TO BE BOUND BY THEM. Students Signature: ___________________________________ Date: _________________________________

cpt@unva.edu

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Revised 1/2011