Pharmacy Technician Training Document

PHARMACY TECHNICIAN TRAINING AGREEMENT

This Pharmacy Technician Training Agreement (the Agreement) sets forth the terms and conditions under which the Training Provider will deliver theoretical and practical instruction to the Student and under which the Student agrees to participate in and complete the prescribed program of study. The Student affirms that all information provided in this document is true and correct and consents to the stated policies, checks, and requirements contained herein.

Student Information

Student Name:    Student ID:

Date of Birth:    Email:

Program Enrollment

Program Name:

Program Start Date:    Expected Completion Date:

Prerequisites, Health and Compliance Requirements

The Student must provide proof of required immunizations, current CPR certification if required by clinical partners, and comply with criminal background checks and drug testing as conditions of clinical placement. Failure to satisfy these requirements may result in denial of clinical placement or dismissal from the program.

Tuberculosis screening provided    Hepatitis B series documented    MMR documented

Varicella documented    CPR certification current    Influenza vaccine provided when required

Background Checks, Drug Testing and Records Release

The Student hereby authorizes the Training Provider and its clinical partners to obtain criminal background checks, motor vehicle records where applicable, and drug screening results as a condition of participation in clinical practicums. Adverse findings that preclude clinical placement may result in withdrawal or failure to certify completion. The Student authorizes release of necessary educational records to clinical sites and certifying bodies for the purpose of placement and credentialing.

I authorize criminal background checks and records inquiries as described above.

I consent to drug and alcohol testing as required by the program or clinical placement.

Attendance, Evaluations, and Competency

Regular attendance, participation in didactic and laboratory sessions, and successful demonstration of clinical competencies are mandatory. Clinical competencies will be evaluated using objective checklists and supervised demonstrations. The Student must achieve all required competencies and satisfy instructor and clinical partner evaluations to receive a certificate of completion. The Training Provider retains sole discretion to determine satisfactory performance based on published rubrics.

Privacy and Confidentiality

The Student shall maintain confidentiality of patient information encountered during clinical education in accordance with applicable privacy laws and institutional policies. Unauthorized use or disclosure of protected health information will result in immediate corrective action, which may include removal from clinical placement or program dismissal.

I acknowledge and agree to comply with confidentiality and privacy obligations.

Clinical Externship Placement

Clinical externship placement is subject to availability and acceptance by external clinical partners. The Training Provider will make reasonable efforts to secure placements; however, placement is not guaranteed. The Student must comply with each site’s policies and requirements. The Training Provider is not liable for placement denials resulting from background, health, or credential concerns.

I consent to clinical externship placement and agree to comply with site-specific requirements.

Fees, Refunds and Withdrawal

Tuition and fees are due under the payment terms set forth above. Cancellation and refund policies apply as follows: any tuition refund requests must be made in writing; tuition refunds will be handled according to the Training Provider’s published refund schedule. The Student is responsible for all non-refundable fees and materials once instruction has commenced. Financial obligations must be satisfied prior to issuance of any completion certificate.

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Student Declarations and Consents

By signing below, the Student certifies that they have read, understood, and agree to comply with the Program requirements, policies, and standards set forth in this Agreement. The Student acknowledges that falsification of records or failure to disclose disqualifying information may result in disciplinary action, up to and including dismissal. The Student consents to the release of educational and health records necessary for placement and credentialing, and to communication between the Training Provider and clinical partners regarding performance and compliance.

I certify that the information provided in this document is true and complete to the best of my knowledge.

I consent to the release of records as necessary for clinical placement and certification.

Program Representative Acknowledgment

The Program Representative certifies that the Training Provider will attempt to provide the educational services, resources, and clinical placement opportunities described in this Agreement, subject to clinical partner acceptance and applicable policies.

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