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Consent and Agreement Form

L3 Connect Programs
All form fields are required. The form will not be processed if any of the fields are incomplete. Write N/A if not applicable
INFORMATION ON RECORD
UID

13564

FIRST NAME

Aldrin Allen

LAST NAME

Ysip

EMAIL

Aldrinallenysip@yahoo.com

PHONE

(805) 478-8531

PROGRAM

Clinical Care Extender/Health Care ScholarSITE

White Memorial Medical Center

CONSENT AND AGREEMENT


I have read and understand the rules and regulations as described in the program outline. I will follow all guidelines pertaining to the
course and will follow the instructions of the medical professionals with whom I will be working. It is understood that injuries that occur
while performing my duties that require immediate first aid will be treated at the hospital. Further treatment is required at my own
expense.
Also, it is understood that no guarantee of employment is given. However, the program will provide a reference, including a job
description, if requested.
TRAINING MANUAL CONSENT AND AGREEMENT
I have been given and have thoroughly read and understand the contents of the training manual. I understand that I am solely
responsible for all material presented in the manual. I understand that as new policies are given to me that I am responsible for those as
well.
DRESS CODE CONSENT AND AGREEMENT
I have read and agree to comply with the dress code as stated in the dress code policy outlined in the training manual. I understand that
I will be sent home if I do not follow hospital guidelines.
HEALTH INSURANCE CONSENT AND AGREEMENT
I certify that I have health insurance coverage that meets the definition of minimum essential coverage under the Affordable Care Act.
I shall provide COPE Health Solutions with evidence of such coverage as requested and notify COPE Health Solutions immediately of
any change or cancellation of such coverage. In addition, I shall provide evidence of renewal of such coverage on an annual basis, or
upon request. I understand that having health insurance coverage is a key requirement to participating in the program, and that failure
to maintain health insurance with minimum essential coverage shall result in suspension or termination from the program, as COPE
Health Solutions determines is appropriate, in its sole discretion.
Minimum essential coverage includes certain government-sponsored health plans, employer-sponsored plans, or individual plans
purchased in the health insurance exchange marketplace. Further information about minimum essential coverage may be found
at http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/minimum-essential-coverage.html.
POLICY / GUIDELINE CONSENT AND AGREEMENT
I have read, understand, and agree to comply with policy on rules and regulations. I understand that noncompliance with the policy and
guidelines may result in dismissal from the program.
By signing below, I agree to all rules, regulations and policies outlined above, and give my consent to all aforementioned points.
PROGRAM PARTICIPANT
SIGNATURE
PARENT/GUARDIANS
SIGNATURE
(if under 18 years of age)

DATE

9/14/15