Transportation Consent and Release of Liability

I hereby acknowledge and agree to provide my own transportation to and from the Medical Assistant Internship service site located at

School Site

Address: (School/ Community Health Fair)

Date / Time

Date

Time

Assistant Address: Date

for the purpose of participating in hands-on clinical training.

In consideration of being allowed to participate in this activity, I hereby release and discharge Healthcare Integrated Services (HCIS), its directors, officers, employees, and agents from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me during my transportation to or from the service site, and or participation in clinical services.

I understand that Health Care Integrated Services (HCIS) does not assume any responsibility for the condition or safety of my personal vehicle or for any accidents or incidents that may occur during my travel to or from the service site, and or participation in clinical services.

I acknowledge that I have carefully read this consent and release of liability and fully understand its contents. I voluntarily agree to its terms and sign it of my own free will.

Student's Name *

First

Last

Student ID *

Signature *

Clear Signature

Date *

Parent/ Guardian Signature (if participant is under 18 years old): *

First

Last

Signature *

Clear Signature

Date *