Educational Clinical Workshops Form

Educational Clinical Workshops Form

Workshop Information

Workshop Title:

Date:    Time: to

Format (select applicable): Lecture Hands-on / Skills Simulation Virtual

Continuing Education Units (CEUs) provided: Yes No   If yes, number of CEUs:

Participant Information

Date of Birth:   Student ID (if applicable):

Participant Category: Student Faculty / Staff Healthcare Professional Other

Emergency & Medical Information

In the event of an emergency, I authorize workshop staff to arrange for emergency medical treatment if I am unable to be contacted: I authorize emergency treatment

Confidentiality, Privacy & Clinical Participation

Participation in clinical components of this workshop may involve observation of or interaction with patients. By signing below the participant acknowledges and agrees that all patient-identifiable information observed or disclosed during the workshop is confidential. The participant will not record, copy, transmit, or disclose protected health information and will comply with all applicable institutional privacy and confidentiality policies. Breach of confidentiality may result in removal from the workshop and disciplinary action.

I have received instruction regarding confidentiality obligations and understand that completion of additional privacy training may be required to participate fully in clinical activities: I acknowledge and agree

Photo, Video & Educational Use

The workshop may be photographed or recorded for educational purposes. Select one option: I consent to use of my likeness for educational materials (non-identifying clinical images permitted). I do not consent to the use of my likeness.

Liability, Risks & Release

I understand that participation in clinical skills training and related activities carries inherent risks, including but not limited to bodily injury, exposure to infectious agents, and discomfort. I voluntarily assume all risks associated with participation to the fullest extent permitted by law.

To the extent permitted by law, I release and hold harmless the institution administering the workshop, its trustees, officers, employees, instructors, and agents from liability for claims, demands, damages, and causes of action arising out of my participation, except for acts constituting gross negligence or willful misconduct.

I certify that I am physically and mentally able to participate in the activities described and that I have disclosed all relevant medical conditions above. I agree to follow all safety instructions provided by workshop faculty and staff.

Acknowledgment: I have read and understand the liability, risks, and release language above.

Fees, Payment & Cancellation

Payment method: Credit/Debit Card Invoice / Departmental Charge Other

Cancellation & Refund Policy: Fees are refundable only under the conditions specified by the program. Failure to attend may forfeit fees; partial refunds at the discretion of the program director. Requests for cancellation must be submitted in writing to program administration prior to the published deadline.

Attendance, Certification & Records

Certificate issuance and CEU credit require documented attendance and satisfactory completion of any required skills assessments. The institution reserves the right to withhold certification for failure to meet performance or attendance standards.

Records: Participant registration and completion records will be maintained by the program for academic and accreditation purposes. By signing below, I consent to the collection and retention of my contact and attendance information for these purposes.

Additional Declarations

Acknowledgments & Certifications

By signing below I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that falsification of information may result in denial of participation or disciplinary action.

If the participant is under 18 years of age at the time of the workshop, a parent or legal guardian must provide consent. Provide guardian contact information if applicable:

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