Temporary Item #2 Please enable JavaScript in your browser to complete this form.IMPORTANT: Your consent and commitment along with your parent's (guardian) is required. The following form must be completed and submitted ASAP, and Ii is mandatory for all students to be in attendance on the first day of the Program at Alain LeRoy Locke Academy campus. Student Name *FirstLastParent/ Guardian Name *FirstLastParent/Guardian ConsentI hereby consent to his/her enrollment as a student in the Health Care Integrated Services – Medical Assistant Apprenticeship Summer Program Part 2. In addition to such consent, I hereby acknowledge and accept the following conditions of enrollment: My child will be subject to the rules, regulations and policies of the Medical Assistant Program, including mandatory attendance both online and in-class attendance. All requests for excused absences, excluding Clinic Holidays, and clinic closures due to severe weather, must be supported with documentation and provided along with the clinic make-up request form at the time the make-up request is submitted. My child may be exposed to discussions, reading and visual material of a mature nature and will be expected to conform to the same performance standards as any other medical professional as set forth in course outlines, syllabi and HIPAA guidelines. I hereby consent my child to participate in the Summer paid intership program. Which includes but not limited to: Fulfill job duties competently perform the tasks and objectives outlined in your job description. This includes adhering to quality standards and deadlines. Uphold professional conduct cultivating a respectful and professional demeanor towards colleagues, clients, and customers. This encompasses fostering a work environment free of discrimination and harassment. Exhibit reliability and punctuality which demonstrates a commitment to your work schedule by arriving on time for assigned shifts and meetings. Maintain consistent attendance and manage time effectively. (4) Practice honesty and integrity while adhering to ethical principles in all work-related activities. Avoid conflicts of interest and be transparent in your dealings. Internship Program MA Student interns are expected to adhere to the Health Care Integrated Services Professional Code of Conduct and the Green Dot Public Schools General Code of Conduct as outlined in the Green Dot Student Policy Manual. Given the academic rigor and professional nature of the apprenticeship program, participants are held to high standards of professional conduct both in the classroom and during their apprenticeship. The following behavior policies have been established to prepare Medical Assistant Student Interns for respectful and professional interactions with school and clinical staff, students, and patients in educational and medical settings. Violations of the Code of Conduct Policy, unless exempted as specified in the rules, regulations, and policies of the Medical Assistant Program, will be reported to Green Dot and the administrators of Alain LeRoy Locke Academy. Additional actions may include removal from the HCIS Summer Paid Internship Program. GENERAL RULES The rigorous nature of the MA program demands an environment that is free from disruption and fosters mutual respect among students, staff, patients and members of the community. To accomplish this end, clear rules concerning student behavior will be strictly enforced for all students, whether on the School premises or participating in School-sponsored activities: Internship ProgramI hereby acknowledge and accept the following conditions of enrollment: I am expected to be subject to the rules, regulations and policies of the Medical Assistant Program, including mandatory attendance both online and in-class attendance. All requests for excused absences, excluding Clinic Holidays, and clinic closures due to severe weather, must be supported with documentation and provided along with the clinic make-up request form at the time the make-up request is submitted. I am expected and required to behave in a respectful manner toward other students, staff, and property. I am expected to demonstrate respect for fellow students and staff members. HCIS does not tolerate any language or behavior that intimidates, belittles, or causes physical or emotional injury to others. I am expected to promote respect for all individuals, and as such, certain behaviors are strictly prohibited on school premises. Prohibited behaviors include, but are not limited to, weapons, knives, any behavior that is harmful to myself and others, the use of derogatory statements in reference to race, sexuality, gender expression, ethnicity, culture, religious background, disability, or any other classification protected by law. I am entitled to a disruption-free, educational environment. No student may disrupt another student’s learning, and classroom disruptions of any kind will not be tolerated. I am expected to comply with verbal directions of all staff members, both in the classroom and in a medical office setting.Parent/Guardian Digital Signature Clear Signature Student Digital Signature Clear Signature Submit Item #3 Please enable JavaScript in your browser to complete this form.Student Apprentice Parental ConsentStudent Name *FirstMiddleLastCheckboxesI hereby consent to his/her enrollment as a student in the Health Care Integrated Services – Medical Assistant Apprenticeship Program. In addition to such consent, I hereby acknowledge and accept the following conditions of enrollment:1. My child will be subject to the rules, regulations and policies of medical personnel (including: Health Screening, TB Test and Health Insurance). 2. My child may be exposed to discussions, reading and visual material of a mature nature and will be expected to conform to the same performance standards as any other medical professional as set forth in course outlines, syllabi and HIPAA guidelines.Parent Certification and ReleaseParent Initial 1I understand that all tuition/fees/textbook costs for any apprenticeship coursework at Health Care Integrated Services, shall be covered by the agency or work site for my child during his/her apprenticeship.Parent Initial 2I understand that a parent or guardian must attend, along with my child, any orientation session or meeting that may be required for the Youth Apprenticeship program.Parent Initial 3I authorize the release of transcripts of grades and attendance records to the U.S. A Department of Apprenticeship.Parent Initial 4I authorize the Youth Apprenticeship Coordinator the use of written or oral testimonials and photographs and/or video or digital recordings with my child’s image in Youth Apprenticeship publications and/or news releases.Parent Initial 5I understand that I am solely responsible for the transportation of the undersigned student to and/or from the classroom or work site and for all loss involved in said transportation.Parent (or Legal Guardian) InformationName *FirstMiddleLastAddressAddress Line 1CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *PhoneSignaturePlease provide your full name and date SignatureDateSubmit
