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Because we are using this for your student ID, please include only your head and shoulders in the image.
Employment Information
Educational Information
Household Information
Please select the statement below that best describes how you first learned about our program.
Demographics
INTERLOCAL ASSOCIATION WORK EXPERIENCE INTERNSHIP
LIABILITY WAIVER & ACKNOWLEDGEMENT OF RISK: COVID-19
I herby acknowledge that I have chosen to participate in a work experience program, organized and operated by Interlocal Association. I understand that COVID-19 has
been declared a worldwide pandemic by the World Health Organization and that it is extremely contagious and is spread mainly from person to person contact. By signing this waiver, I acknowledge that by participating in the work experience program I will be required to follow Reopen Indiana policies and guidance set forth by Governor Holcomb.
I voluntarily agree, to assume the risk and accept sole responsibility that I may be exposed to or infected by COVID-19 by participating in the work experience program and that such exposure or infection may result in personal injury, illness, permanent disability and death. I also exempt, release and indemnify Interlocal
Association, its board members, instructors, employees, students, fimders, host worksites and volunteers from any and all cause of action, liability claims, and demands whatsoever. I will not hold Interlocal Association liable for any injury (including but not limited to: personal injury, disability and death), illness, damage, loss, claim, liability or expense of any kind that I or my family may experience or incur in connection with my participation in the work experience program. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of Interlocal Association, its employees, board members, participants, funders, host work sites, volunteers, and representatives whether a COVID-19 infection occurs before, during, or after participation in any Interlocal Association work experience or other progrannuing
service.
Photo Release
We love to celebrate success with our students, and we often do that through pictures, articles, slideshows, and other fun media. In order for you to participate in that, we will need your permission to use your photo.
I grant this adult ed program, its representatives and employees the right to take and/or use provided photographs of me in connection with documents and promotional materials published by the same. I authorize this adult ed program, its representatives and employees, to use and publish the same in print and/or electronically.
I agree that Area 30 Adult Education may use such photographs of me, with or without my name, for purposes including training and instruction manuals, promotional materials, and electronic documents.
INTERLOCAL ASSCOIATION WPRK EXPERIENCE/INTERNSHIP RULES AND CODE OF CONDUCT
Typing your name in the field(s) below will constitute your electronic signature(s) for the above provided information. Please verify that all information is accurate and that you agree before you sign. Applicants who are under 18 years of age will require a parent/guardian signature as well.
