Healthcare Clinical Training Program

Healthcare Clinical Training Program Enrollment and Authorization

Program Name:   Training Location / Facility:

Trainee Information

Educational Institution / Program Sponsor

Emergency Contact

Insurance Information

Health & Immunization Requirements

Trainees must provide documentation of required immunizations and testing prior to patient contact. Enter dates below for submitted documentation.

Medical History

Background Screening, Drug Testing & Certification

I authorize the program and assigned clinical sites to obtain background checks, criminal records checks, and drug and alcohol screening as a condition of placement. I understand placement may be denied or revoked based on results.

I consent to background and drug screening as described above.

CPR/Basic Life Support Requirement: Trainees assigned to patient care areas must maintain current CPR/BLS certification. Proof of certification must be provided prior to patient contact.

I have provided or will provide proof of current CPR/BLS certification.

HIPAA Privacy & Confidentiality Acknowledgment

As a participant in the Clinical Training Program, I will have access to protected health information for educational purposes under supervision. I understand my obligations under applicable privacy laws and facility policies to safeguard patient information.

I acknowledge that I have read and understand the confidentiality and HIPAA requirements and agree to comply with them.

Access to Clinical Records for Educational Purposes

I authorize supervised access to de-identified or directly relevant patient records for the exclusive purpose of clinical education and training. Access is limited to activities authorized by program faculty and the clinical site.

I consent to supervised access to clinical records as stated above.

Acknowledgment of Policies, Risk & Indemnification

I agree to comply with all facility and program policies including safety protocols, infection control, and scope of practice limitations. I understand that patient care activities carry inherent risks and I assume responsibility for my actions while under supervision.

I release and hold harmless the educational institution, clinical site, and their employees from liability for incidental injury or exposure arising from my authorized participation, except for gross negligence or willful misconduct. I will indemnify the institution and clinical site for claims arising from my negligent acts.

I have read and accept the terms of risk, release, and indemnification contained in this section.

Attendance, Conduct & Termination

Trainees are required to attend assigned clinical hours and to conduct themselves according to professional standards. The program or clinical site may suspend or terminate placement for violations, unsafe behavior, failure to meet health or background requirements, or unsatisfactory performance.

I understand the attendance, conduct, and termination policies and accept them as conditions of participation.

Certification

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 or omission of required information may result in denial or revocation of clinical placement.

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