* denotes required fields.

I, the undersigned student in a Health Occupation education program at Kirkwood Community College, understand that participation in a clinical experience is a requirement of the Health Occupation program and may be a requirement in order for me to receive state or national licensure.  I acknowledge that this may include a clinical experience with an affiliating agency, which includes health care providers and health care entities.  I further understand that an affiliating agency may establish requirements for on-site participation of Kirkwood students in their clinical settings and that these requirements may apply to all agency employees and volunteers and that these requirements may be mandated by state, federal or accrediting agencies of the affiliated agency.  I understand that these affiliating agency requirements may include the following:

(please initial each requirement): 

 1) Background Record Checks.  Submission of my name (including all current and former last names and aliases) to criminal record, dependent adult abuse, child abuse and sex offender checks ("Background Record Checks").  I understand that it is my on-going obligation as a program participant to report any criminal activity or abuse events in which I am involved if such activity or event occurs after the Background Records Checks have been performed.  I grant Kirkwood permission for the Division of Criminal Investigation (DCI) to conduct criminal history checks and to release the results to Kirkwood Community College or the applicable affiliating agency, so that I may be screened by the applicable agency to determine if I may be placed as a clinical intern in its clinical experience program.

 2) Drug Testing.  Submission to drug testing.  I understand that, if required by the affiliating agency, I am required to obtain the required drug test and submit the test results directly to Kirkwood Community College.  I grant Kirkwood permission to release my drug test results to the applicable affiliating agency, so I may be screened by the applicable agency to determine if I may be placed as a clinical intern in its clinical experience program.

I understand that any adverse report or result from the Background Record Checks or the drug test may jeopardize or result in denial of my clinical placement.  I freely accept these additional clinical requirements and all of the associated risks of a denial of my participation in a clinical experience program, including but not limited to my failure to successfully meet all of the requirements necessary to graduate from the Kirkwood health sciences program.

I understand these records will be maintained Kirkwood Community College for two years.

I hereby release Kirkwood Community College, its employees, and all affiliating agencies from any and all liability with regard to my participation in a clinical experience and any decisions based on the Background Records Check or the drug test made concerning my participation in a clinical experience program.

I understand DHS may not evaluate the following records; therefore I may not be able to attend clinic if I have: 1) a juvenile charge and/or 2) a charge without final disposition.  I understand it is my responsibility to have the juvenile charge removed and/or have the final disposition on my record before DHS will evaluate my record.

Disclaimer: This is not a class registration.

*Last Name:

                             

*First Name:

*Middle Name:

*Maiden Name/Alias:
(Put n/a if this does not apply)

*KCC Program:

*Phone Number:

*Street Address:

*City:
*State:
*Zip:

*Date Completed:

*Class Start Date:

*Gender:

Male   Female

*Electronic Signature:
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terms and conditions of this request.