Student Liability Release Form printable pdf download

San Francisco State University

Cooperative Education Program

College of Science and Engineering

STUDENT LIABILITY RELEASE FORM

I, _______________________________________________, hereby knowingly enter into contract

with the Cooperative Education Program of San Francisco State University College of Science &

Engineering, on this day, _____________________.

I agree to hold harmless the Cooperative Education (Co-op) Program and its affiliates from any liable

accidental physical injury to myself or to others while I am at my work site. I further shall NOT hold San

Francisco State University and its affiliates responsible for any legal liabilities, which may result from my Co-

op intern placement.

I shall assume legal liability for taxes on wages, tips or bonuses earned while working in the Co-op Program

intern placement.

It is my personal responsibility to find out how Co-op will affect my financial aid and/or student visa.

I hereby authorize the Cooperative Education Program staff to:

Issue, through University accounting, appropriate tax forms and/or request them when appropriate.

Request and process registration material necessary for my placement and retention in the program

relevant to awarding academic credit for any field work done. I further agree that I have prior

knowledge of mandatory enrollment in the All University Co-op placement course (AU 693 or

793), which requires enrollment for 1 to 12 units of credit for Co-op placements. Therefore, this

clause shall allow the Co-op staff to act independently and may process enrollment in the Co-op

units to ensure compliance with this requirement if I am unable or fail to do so.

In addition, I understand that:

Participation in the Co-op Program does not guarantee placement.

I must notify the Co-op office of all interviews and offers.

Upon acceptance of a Co-op position, I must contact the Co-op office and complete the appropriate

forms.

By enrolling in the Co-op Program, I am hereby giving my consent and authority to

the Co-op Program to access by transcripts as necessary.

I give my consent to the Co-op Program to release a copy of my resume, and unofficial transcript to

employers for the purposes of assisting me in obtaining a Co-op position.

I have read and agree to all the above conditions.

Signature________________________ Print Name____________________________

S.S. #

__________________________ Today’s Date __________________________

1600 Holloway Avenue, Science 248, San Francisco, CA 94132-4163 | Phone: 415.338.1050 Fax: 415.338.0548 | Email: cooped@sfsu.edu

Student Liability Release Form