Internship Notice of Intent 2023 Student Internship Program Form Notice of Intent + Liability Waiver + Student Evaluation Step 1 of 3 33% Chair Approval Yes No Chair NotesStudent Name First Last Student Email Are you a part-time student?” No Yes Will adding this internship to your schedule change your part-time status? Yes No How many units of credit are you seeking?” 0 units 1 unit (50 hrs) 2 units (100hrs) 3 units(150 hrs) Are you a student on an F1 VISA ? Yes No Will adding this internship to your schedule put you above 18 units (overload)? Yes No MajorAnimationDrawing + PaintingDrawing + Painting Sculpture EmphasisDrawing + Painting with Illustration EmphasisExperimental AnimationGame ArtGraphic Design + Digital MediaGraphic Design + Digital Media with Action Sports EmphasisGraphic Design with Illustration EmphasisIllustrationIllustration with Drawing + Painting EmphasisIllustration with Entertainment EmphasisIllustration in Entertainment DesignMFA - Art of Game DesignMFA - PaintingMFA - DrawingPOST-BACC - Drawing + PaintingSemester and year in which you will be completing the InternshipFall 2022Spring 2023Summer 2023Fall 2023Spring 2024Summer 2024Fall 2024Chair Name First Last Chair Email The type of work to be performed by this student during the internship is as follows:Company Name Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Supervisor Name First Last Supervisor Email Supervisor PhoneHow did you hear about this opportunity? LCAD Job Board LinkedIn Faculty Family/Friends Other Do you want to use this internship to substitute for a course *Substitutions are subject to Chair approval*? Yes No Course Name Course Number Are you a veteran? Yes No Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Wage or Salary if Any I First Last , am a current student at Laguna College of Art + Design (“LCAD”), and in consideration of being permitted to attend and participate in a credit-eligible off-campus internship program (“Program”) offered and conducted bySponsor First Last , I voluntarily and knowingly agree as follows: 1. Purpose. It is the purpose of this Liability Waiver, Release, and Assumption of Risk Agreement (“Agreement”) to waive, release and discharge LCAD and its faculty, staff, employees, board members, and agents (“Released Parties”) from any and all liability and damages arising out of my participation in the Program. 2. Independent Investigation and Assumption of Risk. I represent and warrant that I have independently investigated all aspects of the Program and its Sponsor and am not relying upon any representations or promises made by LCAD in connection with the Program. I am aware that my participation in the Program involves certain risks, dangers and hazards, including, without limitation, transportation to the off-site location of the Program and the utilization of the Sponsor’s equipment, materials and supplies. I freely and fully assume all risks, dangers and hazards associated with my participation in the Program. 3. Medical Insurance Certification. I certify that I have personal medical, disability, hospitalization and/or accident insurance sufficient to cover me during my participation in the Program. I understand that I am responsible for the costs of such insurance and for the expenses not covered by this insurance, and I recognize that LCAD does not have an obligation to provide me with such insurance. 4. Liability Waiver and Release. In consideration of LCAD’s approval to participate in the Program, I hereby fully waive, release and discharge the Released Parties from and against all rights, claims, causes of action or damages of any kind whatsoever related to or arising out of my participation in the Program, including, without, limitation, personal injury or damages (physical or mental), illness, wrongful death, theft or damage to personal property. I agree not to bring any legal action against any of the Released Parties for the claims being released in this Agreement. I understand that if I use my personal vehicle or property for the benefit of the Program, LCAD has no liability for personal injury or property loss or damage which may result from that use. 5. Miscellaneous. In the event that any provision contained in this Agreement is deemed to be severable or invalid, unlawful or otherwise unenforceable, the remainder shall remain in full force and effect. -2- I am over the age of 18 and fully competent to sign this Agreement. I understand and agree that this Agreement is intended to be as broad and inclusive as permitted by the laws of the State of California. I certify that I have read this Agreement, that I fully understand its contents and voluntarily sign it. I agree that no oral representations, statements, or other inducements to sign have been made apart from what is written in this Agreement. I am over the age of 18 and fully competent to sign this Agreement. I understand and agree that this Agreement is intended to be as broad and inclusive as permitted by the laws of the State of California. I certify that I have read this Agreement, that I fully understand its contents and voluntarily sign it. I agree that no oral representations, statements, or other inducements to sign have been made apart from what is written in this Agreement.SignatureHiddenChair Approval Yes No This section is to be completed after the internshipDid your education at LCAD prepare you well for this internship? Yes No What new skills and/or techniques did you learn in your position ?Did this internship increase your interest in this field as a future career? Yes No What were the greatest challenges you faced during this internship ?Were you lacking any skills ? No Lacked skills to do the job Company was not organized Workload balance What recomendations do you make to future interns with this company ?