Student Cardiovascular Unit Enrollment Form

Student Cardiovascular Unit Enrollment Form

Student Information

Student Name:

Parent / Guardian (if applicable)

Is the student a minor? Yes

Program Enrollment Details

Program Start Date:    Expected End Date:

Prerequisites and Health Clearance

I affirm that the student meets required prerequisites (health science coursework, immunizations, and clinical clearances) and understands that enrollment is conditional upon verification of documentation.

Emergency Contact & Medical Information

Current Medications:

Insurance & Billing (if applicable)

Program Policies, Risks, and Acknowledgments

Assumption of Risk: Clinical activities in the cardiovascular unit involve direct patient contact, exposure to medical equipment, and physical tasks. I acknowledge these risks and assume responsibility for participation. The institution and clinical affiliates are not liable for injury except as provided by law.

Confidentiality and Protected Health Information: Students will access confidential patient information. I agree to comply with all confidentiality policies and to protect patient privacy. Unauthorized disclosure may result in disciplinary action or legal liability.

Attendance and Conduct: Students must comply with attendance, dress code, immunization, and safety requirements established by the program and clinical sites. Failure to adhere may result in removal from the unit and loss of credit.

Consent and Authorizations

Emergency Medical Treatment Authorization: In the event of an emergency, I authorize program personnel and clinical affiliates to obtain and provide necessary emergency treatment for the student. I agree to be responsible for expenses incurred for emergency medical care.

Photography / Video: I consent to the use of photographs or video recordings of the student for educational and program documentation purposes unless I explicitly withhold consent below.

Withhold consent for photography/video: Yes

Academic and Financial Terms

Enrollment is subject to academic evaluation and may carry tuition, fees, or liability insurance charges. Refunds or withdrawals follow the program's published policies. The student or responsible party is financially responsible for all applicable charges unless a third party arrangement is documented in writing.

Certification

By signing below, I certify that the information provided is true and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information may result in denial of enrollment or removal from the program. I consent to the processing and verification of required documentation by the educational institution and clinical partners.

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