IIC Intern Agreement

IIC Intern Agreement
Intern Name*

First NameLast Name
Intern E-mail*
Intern Phone Number*

Area CodePhone Number
Intern Date of Birth*

MonthDayYear
Current Residential Address (PO Boxes NOT Accepted)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
T-Number
Will your internship be remote?*

YesNo
Does this internship take place outside the State of Utah?*

YesNo
Worksite Location*
Physical Address of Worksite Location (This is for tax purposes)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Intern Veteran Status*

ActiveNon-ActiveNon-Veteran
Gender*
Ethnicity*
SUU Minors Policy : Are you under the age of 18?*

YesNo
Guardian's Email*
example@example.com
SUU Employment Status:*

I have been / currently am employed by Southern Utah UniversityI have been employed by Southern Utah University, but it has been longer than 12 monthsI have never been employed by Southern Utah University
Agency & Mentor Information
Agency*

National Park ServiceUnited States Forest ServiceBureau of Land ManagementIIC/Outdoors Pathways DeptU.S. Fish and WildlifeNPS GIS CohortForest Inventory & AnalysisOther
Agency Mentor Name*

First NameLast Name
Agency Mentor Email*
example@example.com
Education
Are you currently enrolled in school? (High School/College)*

YesNo
Recent or Current School Status*
Previous or Current University/School Name*
Current Year in School?*

FreshmanSophomoreJuniorSeniorGraduate SchoolRecent Graduate
Year of High School or College Graduation?*
N/A if not applicable
Major*
Minor
SUU Internship Requirements
All IIC internships include an intern orientation, online training, and assignments.*

I agree to complete IIC/SUU intern orientation, online training, assignments, and any required certifications (such as Defensive Driving or First Aid/CPR).
Interns may be eligible for academic credit through their University or faculty advisor. It is your responsibility to coordinate arrangements prior to beginning an internship.

SUU students can reach out to Kevin Koontz, Outdoor Academic Coordinator at kevinkoontz@suu.edu with questions.
Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship*
Emergency Contact Phone*

Area CodePhone Number
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Internships are subject to SUU Policy #6.3: Internships

By checking the box "I agree to the terms and conditions set by this agreement" you agree that you have read and understand this policy.
SUU Policy #6.3 Agreement

I agree to the terms and conditions set by this agreement.
Photo Release

By submitting this agreement, you hereby give permission to Southern Utah University and the IIC to use your name and photographic likeness, without restriction, in all forms and media for advertising, trade, and any other lawful purposes. You agree that there is no consideration or compensation due as a result of granting this permission.
Photo Release Agreement

I agree to the terms and conditions set by this agreement.
Intern's Responsibilities
- Comply with Agency's rules, policies, and procedures.
- Complete the internship during the dates specified unless modified by the Agency and SUU.
- Work conscientiously under the direction of the Mentor assigned by the Agency, submitting all reports and assignments as required.
- Report serious problems, including physical, safety, personnel, and other observed risk issues to the Agency Internship Mentor and the SUU/Departmental Internship Coordinator.
- Accept risks involved during the internship program. Participation as an intern may involve risks not found in study at the institution. These include risks involved in traveling to and from the place of internship; different standards of design, safety, and maintenance of buildings, public places, and conveyances; local medical and weather conditions. The intern represents that he/she has conducted a risk investigation and is willing to accept these risks.
- Consult with his/her personal physician in regard to necessary immunizations and any other medical matters relating to participation in the internship program.
- Authorize SUU's designated representative to grant permission for any necessary medical treatment, if, during participation in the program, such intern shall become incapacitated or otherwise unable to provide consent for medical treatment and advance consent cannot be obtained from the intern's family/guardians.
- Be personally responsible for all housing, transportation, study, and other arrangements in connection with the internship and personally bear all associated costs, unless these are provided by the Agency. In addition, be personally responsible for any financial liability and obligation which is incurred, and for any injury, loss, damage, liability, cost, or expense to the person or property of another which is caused or contributed to by the intern during participation in the internship program.
- Abide by all applicable laws. Interns should understand that he/she must personally attend to any legal problems encountered or incurred as an intern.
  Any other requirements, expectations, or related internship documentation, as established by the Host Agency, should be appended to this agreement.
Responsibility Agreement*

I agree to the terms and conditions set by this agreement.
Should be Empty:

IIC Intern Agreement

Agency & Mentor Information

Education

SUU Internship Requirements

Emergency Contact

Internships are subject to SUU Policy #6.3: Internships

Photo Release

Intern's Responsibilities