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\b\fs28\cf1\insrsid14766794 FORM 3 INTERNSHIP STATEMENT OF INSURANCE COVERAGE }{\rtlch\fcs1 \af39 \ltrch\fcs0 \fs28\cf1\insrsid14766794 
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\ltrch\fcs0 \f40\fs23\insrsid14766794 The Board of Trustees of @ 2026 黑料不打烊 on behalf of \line The Department of Instructional Design & Technology{\*\bkmkstart name}}{\field{\*\fldinst {\rtlch\fcs1 \af40 \ltrch\fcs0 
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\par 
\par I, _____________________________, certify that I have paid for the Student Health and (Student\rquote s Name) 
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\par Major Medical Program which is provided to @ 2026 黑料不打烊 Students (or have voluntarily waived University Insurance by providing, verifying, and maintaining an equivalent policy through a private insuranc
e representative) and that I will not cancel or change this insurance coverage during the period of my Internship. 
\par 
\par I further represent that I am above the age of 21 years,* with full understanding of all risk involved and agree that this \'93Statement of Insurance\'94 shall be binding upon my heirs, executors, administrators, and assignors. 
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\par * For persons under the age of 21, parental signature required: 
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