Internship Waiver Of Liability & Hold Harmless Agreement Form
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2Internship Waiver of Liability & Hold Harmless Agreement
I, the undersigned participant, am requesting participation in the CSU, Northridge,
Name of department and college: ______________________________________________________________________
Activity: __________________________________________________________________________________________
that begins on: _________________________________
and ends on: __________________________________
In consideration for being allowed to participate in this Activity, on behalf of myself and my next of kin, heirs and
representatives, I release from all liability and promise not to sue the State of California; the Trustees of The California
State University; California State University, Northridge and their employees, officers, directors, volunteers and agents
(collectively “University”) from any and all claims, including claims of the University’s negligence, resulting in any physical
or psychological injury (including paralysis and death), illness, damages, or economic or emotional loss I may suffer because
of my participation in this Activity, including travel to, from and during the Activity.
I am voluntarily participating in this Activity. I am aware of the risks associated with traveling to/from and participating in
this Activity, which include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement,
temporary or permanent disability (including paralysis), economic or emotional loss, and/or death. I understand that these
injuries or outcomes may arise from my own or other’s actions, inaction, or negligence; conditions related to travel; or the
condition of the Activity location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my
participation in this Activity, including travel to, from and during the Activity.
I agree to hold the University harmless from any and all claims, including attorney’s fees or damage to my personal
property, that may occur as a result of my participation in this Activity, including travel to, from and during the Activity. If
the University incurs any of these types of expenses, I agree to reimburse the University. If I need medical treatment, I
agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I
should carry my own health insurance.
I am 18 years or older. I understand the legal consequences of signing this document, including (a) releasing the
University from all liability, (b) promising not to sue the University, (c) and assuming all risks of participating in this
Activity, including travel to, from and during the Activity.
I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I
agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms.
I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document
have been made to me.
Participant’s Signature :_____________________________________________________ Date:_______________________
Print Participant’s Name ____________________________________________________ Phone No: ___________________
Instructor’s Signature ______________________________________________________ Date:________________________
Print Instructor’s Name: ____________________________________________________ Phone No: ___________________
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