WHEREAS, the Criminal Justice Program of University of Illinois at Chicago has entered into agreements with various criminal justice agencies by which such agencies have agreed to accept certain qualified students in the Criminal Justice Program as interns with such agencies for the purpose of furthering the education of such students, and WHEREAS, I have been accepted by
_________________________________________ (name of agency accepting intern) as such an intern, and whereas, the internship program will include observing the function of the agencies, and participating in other agency activities, as directed.

NOW THEREFORE, I hereby, in consideration of my acceptance as such an intern by the above named agency and the efforts of UIC in securing such placement, do release and waive any and all claims or demands of whatsoever nature which I now have or may in the future acquire against said UIC and
______________________________________ (name of agency accepting intern)

together with the officers, agents, servants and employees of UIC and the
___________________________ resulting from my service as such intern. (name of agency accepting intern)

I further covenant and agree, in consideration of my placement and acceptance as such intern to indemnify and hold harmless said University and accepting agency and their employees from any liability which may be incurred by them or either of them, proximately resulting from any acts by me during such internship, realizing that I have the right to reject experiences that are beyond my level of experience. I further represent that I have a full understanding of all risks involved and agree that this waiver and release shall be binding upon my heirs, executors, administrators, and assignors.

Name of Student: ____________________________________________

Signature: ____________________________________________

Date: ________________________