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AOES Xtern Registration

Student Information
Name:
Student ID#:
Email:
Company Information
Company Name:
Department (if applicable):
Externship Supervisor:
Email:
Phone:
How many hours per week will the student work?:
What are the start and finish dates of the externship?: -
Days each week (check all that apply):	MonTueWedThuFriSatSun
I HAVE READ AND UNDERSTAND THE EXTERNSHIP REGISTRATION AGREEMENT AND AGREE TO BE BOUND BY THE TERMS OF THE AGREEMENT.

Externship Registration Agreement

I understand that participation in this externship is entirely voluntary and that any such externship program involves some element of risk. I agree that in consideration of the above mentioned Company, Supervisor, and AAPC sponsoring this activity and permitting me to participate, I will indemnify, defend and hold harmless , , and AAPC, its officers, agents, employees, successors and assigns from liability for any and all claims, demands, rights or causes of action, present or future, resulting from or arising out of any travel or activity conducted by or under the auspices of this externship program.

I understand that AAPC suggests that all students be covered by appropriate accident and medical insurance and that the student be financially responsible for such expenses.

AOES Xtern Registration

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