Intern Project Insurance Waiver Form
Complete this form to provide your intern and project details and acknowledge the project-related insurance waiver information.
Participant Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization or University Affiliation
*
Intern Project Details
Project or Team Name
*
Project Location or Department
*
Internship Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Internship End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor or Host Contact Name
*
First Name
Middle Name
Last Name
Waiver Acknowledgement and Signature
Signature
*
Signed Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: