Student Job Shadowing Application

NATAS Job Shadowing Student Application

Job Shadowing Week: March 2nd-6th 2015
Please complete all the information requested below. This enables us to get back to you promptly.

Student Information:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail
School Information*

MajorCollege/University
Class Year *
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Please answer the following questions:
1.What are your Career Goals? *
2. How would particpating in NATAS job shadowing help you to achieve your goals? *
3.Have you particpated in NATAS job shadowing previously? If so, when? *
Please specify availability to job shadow:*

MonthDayYearHourMinutesAM/PM Option
Please select area of interest (select only one): *
Notice Concerning Insurance Coverage while Participating in this Program
The National Academy of Television Arts & Sciences Pacific Southwest Chapter is not responsible in the event of personal injury or loss, accidents, or other occurrences during the externship. Students are responsible for their own actions.

________________________________________________________________________

Risk Acknowledgement and Liability Waiver

PLEASE READ CAREFULLY BEFORE CONSENTING

I acknowledge that participation in the Television Academy Job Shadowing Program (herein "program") is completely voluntary and is an opportunity offered for the benefit of a learning experience and not employment, therefore participation does not provide monetary compensation or benefits such as work comp and health insurance coverage through the university nor sponsoring business. I understand that application to the program does not guarantee participation since the opportunity will be dependent upon business sponsor availability in the areas and career fields I have chosen and is limited in number. I further understand that it is my responsibility to provide all transportation and meals needed to fulfill participation in the program, and that program activities could involve certain risks such as those related to travel on highways and congested areas, and I accept those risks and assume full responsibility for any associated injury, property losses, accidents or costs related to program activities. I agree to conduct myself in a professional manner and acknowledge that I am responsible for my own actions during the course of the externship program and understand that either I or the business sponsor may terminate participation at any time.

If placed in an externship, I agree to be available and attend my externship during the week of March 2nd to 6th2015 according to business sponsor’s specified hours.

In consideration of the opportunity afforded me, with full knowledge and appreciation of the risks involved, I hereby agree to indemnify, release and hold harmless; National Academy of Television Arts & Sciences Pacific Southwest Chapter, its staff, trustees, officers, representatives, and agents, from all form and manner of risks inherent and from all claims and demands of any nature arising from my participation in the externship program and related travel. In addition, I agree to comply with all rules applicable to my participation in the program.
Your Agreement*

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NATAS Job Shadowing Student Application

Emergency Contact Information

Please answer the following questions:

Notice Concerning Insurance Coverage while Participating in this Program