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I, , certify that I have paid for the Student Health Insurance
(Students Name)
Program that is provided to ϲʷ¼ Students (or have voluntarily waived University Insurance by providing, verifying, and maintaining an equivalent policy through a private insurance representative) and that I will not cancel or change this insurance coverage during the period of my internship. I further represent that I am above the age of 21 years*, with full understanding of all risk involved and agree that this Statement of Insurance Coverage shall be binding upon my heirs, executors, administrators, and assignors.
Student Signature
Witness Signature
* For persons under the age of 21, parental signature required
Parental Signature
FORM VII
STATEMENT OF INSURANCE COVERAGE
ϲʷ¼
School of Law Enforcement and Justice Administration
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