CLAREMONTGRADUATEUNIVERSITY
MASTEROFPUBLICHEALTHINTERNSHIPPROGRAM
STUDENTLEGALAGREEMENT
Inconsiderationofmyparticipationinasupervisedfieldtrainingexperience,Internship,atClaremontGraduate
University(“CGU”),Iagreeasfollows:
1.
Confidentiality.AsastudentparticipantinanInternship,Imaybecollecting,reviewingoranalyzingdata
frompatientsaboutsensitive,personalaspectsoftheirhealthand/orbehavior(“PatientRecords”).Iunderstand
thatthemaintenanceofconfidentialityisrequiredwhenworkingwithpatientsandclientsinapublichealth
setting.Consequently,IwillnotdisclosePatientRecordsnordiscussinformationaboutapatientwithanyone
otherthanauthorizedindividualsworkingonmyproject.Iagreetomaintainconfidentialityandprotectthe
privacyofpatientsinaccordancewithlawandprofessionalstandards.Inaccordancewiththoseprofessional
standards,ImayonlydisclosePatientRecordsifmaintainingconfidentialitywouldjeopardizethehealthorsafety
ofothers.IunderstandthatimproperdisclosureofPatientRecordscouldleadtotheterminationofmyInternship,
amongotherthings.
2.
ProofofInsurance.StudentsparticipatinginaInternshiparerequiredtohaveandmaintainhealth
insuranceduringtheentiretermoftheInternship,aswellasprovideproofofsuchinsurancepriortobeginning
theInternshipandattherequestoftheInternshipsiteadministrator.Shouldmyhealthinsurancechangeduring
myInternship,IunderstanditismyresponsibilitytoprovideupdatedproofofvalidhealthinsurancetoCGU.By
signingbelowIcertifythatIhavecurrent,validhealthinsurance.Myhealthinsuranceprovideris
___________________________andcoversMajorMedical.Theexpirationofmyhealthinsuranceis
__________________________.(Pleaseattachaphotocopyoftheinsurancecardtothisdocument.)Iunderstand
thatfailuretohaveormaintainvalidhealthinsurancecouldleadtothesuspensionorterminationofmy
Internship.
3.
Workers'Compensation.Asastudent,IunderstandthatIamnotanemployeeofCGUandamtherefore
ineligibletobecoveredbyCGU’sworkers'compensationinsurance.IfIampaidastipendfromtheInternshipsite,
IunderstandthatitismyresponsibilitytoinquirefromthesiteifIwouldbeconsideredanemployeeofthesite
andthereforecoveredbytheirworkers'compensationinsuranceandotherwisesubjecttotheotherobligations
imposeduponemployees.
4.
ReimbursementforHealthCareCosts.IunderstandthatIamresponsibleforpayinganyhealthcarecosts
incurredduringmyInternshipthatmyhealthinsuranceproviderdoesnotpay.InnoeventisCGUresponsiblefor
suchexpenses.Iunderstandthatsincesomehealthinsurancecarriersmaynotreimbursestudentsformedical
treatmentprovidedoutsideofthehealthinsurancecompany’sgroup,itismyresponsibilitytocontactmyhealth
insurancecarriertodeterminewhereandhowIwillreceivetreatmentifinjuredwhileattheInternshipsite.I
shouldalsoinquireifIcanbereimbursedforanytreatmentadministeredattheInternshipsite.
5.
InternshipPoliciesandProcedures.BysigningbelowIcertifythatIhaveread,understood,andagreedto
allofthepoliciesandproceduresoutlinedintheCGUMasterofPublicHealthProgramInternshipaswellasany
additionalguidelinesprovidedtomebytheInternshipsite.Iunderstandthatfailuretoabidebythesepoliciesand
proceduresmayleadtotheterminationofmyparticipationintheInternship,amongotherthings.
6.
ReleaseandIndemnity.IamparticipatingintheInternshipwithfullknowledgeoftherisksinherentin
suchparticipation,includingpossiblephysicalinjury,illness,orotherlossordamageastheresultofworkingfor
extendedperiodsinapublichealthsite,traveltositestoperformpublichealthservices,andworkinginsitesthat
maybedangerousand/orunstableastheresultofnaturaldisaster,politicalunrest,orothervolatilecircumstance.
IagreetoacceptandassumeanyandallrisksassociatedwithparticipationintheInternship.Inconsiderationof
CGU'sacceptingmeintotheInternship,I,myheirs,executors,administrators,employers,agents,representatives,
insurersandattorneys,herebyreleaseanddischargeCGU,itsofficers,trustees,faculty,employees,agentsand
representatives(hereafter"releasedparties")fromanyandallclaimswhichmayarisefromanycausewhatsoever,
regardlessofthesource,exceptforgrossnegligenceorwillfulmisconductonthepartofthereleasedparties,or
anyofthem.Ifurtherreleaseanddischargethereleasedpartiesfromresponsibilityforanyaccident,illness,
negligence,injury,oranyotherconsequencesarisingorresultingdirectlyorindirectlyfrommyparticipationinthe
Practicum,unlesscausedbythegrossnegligenceorwillfulmisconductofthereleasedparties,oranyofthem.I
herebyagreetoindemnifyandholdharmlessthereleasedpartiesfromanylossorliabilitywhatsoeverincluding
reasonableattorneys'fees,causedbymeinthecourseofmyparticipationintheInternship.
7.
InternshipCancellation.IunderstandthatCGUmay,initssolediscretion,cancelorsuspendthe
Internshipforanyeventsorcircumstancesthatmay,inCGU'ssoledetermination,placemeatriskofmental,
emotionalorphysicalharmorbodilyinjury.CGUalsomaycancelorsuspendtheInternshiporsubstituteclasses
duetolowenrollmentsorunavailabilityoffacultyorfacilities.
8.
StudentinGoodStanding.Bysigningbelow,IrepresentthatIamastudentingoodstandingatCGUand
haveneverhadchargesbroughtagainstmebeforetheCGUOfficeofStudentConduct.IherebygivetheOfficeof
StudentAffairstherighttoaccessmyrecordsmaintainedbytheCGUOfficeofStudentConduct,andtoprovide
relevantinformationformsuchrecordstotheInternshipDirector.
9.
IunderstandandagreethatifanyprovisionofthisAgreementortheapplicationthereofisheldinvalid,
theinvalidityshallnotaffectotherprovisionsorapplicationsofthisAgreementwhichshallremainfully
enforceable.
10.
IunderstandandagreethatthisAgreementshallbeconstruedinaccordancewith,andgovernedby,the
lawsoftheStateofCalifornia.SubjecttoapprovalfromCGU'sinsurancecarrier,anydisputearisingfromthis
Agreementshallbesubmittedforfullandfinalresolutiontoarbitrationinaccordancewiththerulespromulgated
bytheAmericanArbitrationAssociation.ThearbitrationshalltakeplaceinLosAngelesCounty,California.
11.
IunderstandthatthisAgreementand,ifapplicable,theMasterofPublicHealthInternshipStudent
TransportationWaiver(DomesticTravel),and/ortheMasterofPublicHealthInternshipReleaseforInternational
Travelarethesoleandcompleteagreementsofthepartiesrelatinginanywaytothesubjectmatterofthese
agreements.Theseagreementsshallberead,interpretedandenforcedinconjunctionwitheachother.No
statements,promisesorrepresentationshavebeenmadebyanypartytoanyother,orreliedupon,andno
considerationhasbeenofferedorpromisedotherthanasexpresslystatedintheseagreements.
IacknowledgethatIhavereadthisAgreementandthatIunderstanditsmeaningandeffect.
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StudentName StudentSignature
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