Student Name:
As a student of this program, I agree to the rules, regulations, policies and procedures as stated below.
1. The program requires a period of assigned, guided clinical experiences either in the college or other
appropriate facility in the community.
2. For educational purposes and practice on “live” models, I will allow other students to practice procedures on
me and I will practice procedures on them under the guidance and direct supervision of my instructor. The
nature and educational objectives of these procedures have been fully explained to me. No guarantee or
assurance has been given to me by any representative of the college as to any problem that might be incurred
as a result of these procedures.
3. These clinical experiences are assigned by the instructor for their educational value and thus no
payment (wages) will be earned or expected.
4. It is understood I will be a student within the clinical facilities that affiliate with my college and will conduct
myself accordingly. I will follow all required and published personnel policies, standards, philosophy, and
procedures of these agencies. I will agree, at my own expense, to obtain all health screenings,
immunizations, criminal background checks, and drug screenings as required by the affiliating agency.
5. I have been provided a copy of, read, and agree to adhere to the college’s policies, rules, and regulations
related to the program for which I am applying.
6. I understand that information regarding a patient or former patient is confidential and may be used only for
clinical purposes within an educational setting according to the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
7. I understand the educational experiences and knowledge gained during the program do not entitle me to a job;
however, if all educational objectives and licensure requirements are successfully attained, I will be qualified
for a job in this occupation.
8. I understand any action on my part inconsistent with the above understandings may result in suspension of
9. I understand that I am liable for my own medical and hospitalization expenses.
10.I understand that I will be accountable for my own actions; therefore, I will carry a minimum
$1,000,000/$3,000,000 (or a greater amount of ______________ as required by the Facility) limited
professional liability insurance during the clinical phase of the program.
I have read and understand each term above, and agree to abide by this statement of understanding.
To be signed by legal guardian if applicant is a minor.
Student Signature:
As the legal guardian of the student named above, I agree to the above conditions.
Somerset Community College