Waiver of Liability
I, ____________________________, being eighteen (18) years of age or older, do
(print name)hereby affirm and swear as follows:
1. I have voluntarily chosen and elected to participate in the Professional Practice Program at Illinois State
2. I willfully and freely assume complete responsibility for any injuries, physical or mental, which I might
sustain by participating in the Professional Practice Program.
3. A representative of the University Insurance Office has explained the Student Health and Accident
Insurance program, as well as the University's Malpractice Liability insurance program. I fully understand
these programs and my responsibilities for coverage.
4. I assume all obligations for payment of state and/or federal taxes.
5. I assume all obligations for complying with all current financial aid regulation (see Financial Aid Office).
6. I acknowledge that if driving is a part of this assignment, I will maintain a current driver's license and
7. I understand that participation in Professional Practice does not entitle me unemployment compensation
at the end of the week term.
8. I understand that it is my responsibility to arrange for registration for the following school term.
9. I assume responsibility for applying for refund of fees if I am eligible as a result of my participation in
10. I do hereby release, acquit, and forever discharge The State of Illinois, Illinois State University, its officers,
employees, attorneys, representatives, insurers, and assigns, each and every person, natural or corporate,
from any and all demands, causes of action and/or judgments of whatsoever nature or character, past or
future, known or unknown, whether in contract or in tort, whether for personal injuries, property damage,
payments, fees, expenses, accounts receivable, credits, refunds, or any other monies due or to become
due, or damages of any kind or nature, which have accrued, and whether arising from common law or
statute, to me, my heirs, executors, legal representatives, successors or assigns, arising out of, in any way,
the Professional Practice Program.
Student Signature _______________________________ Date _____________