Exhibit C: Participant Acknowledgement Form and Rotation Schedule

*This form must be completed by the learner*

Last Name   
First Name   
Email   
Phone Number   
Academic Program (eg., Nursing)   
School   
Faculty Advisor Name & Title   
Faculty Advisor Telephone   
Faculty Advisor Email Address   
Emergency Contact Name   
Emergency Contact Relationship   
Emergency Contact Telephone   
Emergency Contact Alternate Telephone   

The undersigned has applied to participate in a training program through Saint Francis Care, Inc. in Hartford, Connecticut.  He or she understands that the execution and submission of this Participant Acknowledgement is a pre-condition to commencing participation in the training program at Saint Francis.  Learners will not be allowed to engage in training at Saint Francis until all forms have been received, reviewed, and approved. 

By checking the box below, the undersigned hereby acknowledges that he or she has read and understands this Participant Acknowledgement and agrees that:

  1. He or she shall maintain health insurance coverage while participating in the training program at Saint Francis and that he or she is financially responsible for any medical care rendered to him or her at Saint Francis while participating in the training program;
  1. In order to receive health clearance to participate in the training program at Saint Francis, he or she shall be current with the following vaccinations and tests:

       a. Negative PPD documented within 1 year of the intended start date

       b. Documentation of two MMR (mumps, measles, rubella) vaccinations or titers

       c. Proof of positive varicella (chicken pox) titer or two varicella vaccinations

       d. Flu vaccine (if rotation is during flu season)

       e. Any other vaccinations or tests required by Hospital policy

He or she shall provide evidence of the foregoing to Saint Francis by completing and returning Exhibit D to Saint Francis Occupational Health prior to commencing the training program at Saint Francis;

  1. He or she shall abide by all Saint Francis workplace rules, policies, procedures, protocols and directives while participating in the training program at Saint Francis;
  1. His or her failure to abide by all Saint Francis workplace rules, policies, procedures, protocols and directives while on-site at Saint Francis shall result in his or her termination from any training program at Saint Francis;
  1. He or she is not and shall not be eligible to receive any wages, salary, or compensation of any kind for any activities undertaken by the him or her at Saint Francis as part of the training program;
  1. He or she understands that in no event shall he or she represent himself or herself as an agent or employee of Saint Francis; and
  1. Prior to commencing training activities at Saint Francis, he or she shall complete New Learner Orientation and On-boarding Process required by Saint Francis, and shall execute and deliver – to the Program Coordinator at Saint Francis (see below) – the Confidentiality and Non-Disclosure Statement and the Code of Conduct and Corporate Compliance Plan Acknowledgment Statement provided in connection with such orientation. 

Full Name:  

 

Please provide the rotation-specific information requested below

 

 

Department you are Rotating in at Saint Francis:  
Program Coordinator at Saint Francis:   
Your Rotation Site (e.g., Gengras, Mount Sinai Campus):   
Your Saint Francis Rotation Site Supervisor / Preceptor:   
Rotation Start Date:   
Rotation End Date:   

 

 

 

Please direct any questions about the form requirements to learners@stfranciscare.org.