Scholars Permission Form

Permission Form:

As a parent or legal guardian, I affirm that I have been informed of the clinically related activities that my child will be participating in, including:

1. Being inside sterile clinical areas including surgical operating rooms and an imaging center.
2. Changing into and out of sterile scrubs in a gender-specific locker room.
3. Noninvasive eye exams performed by professional staff such as retinal photos and other assessments including color and 3D vision testing.

I understand that MEDARVA Healthcare policy requires that my child must provide proof of COVID-19 Vaccination no later than July 11 to participate in clinical rotations or wear a MEDARVA Healthcare-issued N-95 mask.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

HIPAA is a United States federal statute that governs healthcare organization’s safekeeping of personal medical information. I understand that my student will go through HIPAA training at MEDARVA before being permitted in clinical areas and will be required to sign a form that they understand that as a MEDARVA Scholar, they are not permitted to share any patient information they encounter as part of the program. Such information includes telling ANYONE anything that could identify specific patients they recognize/see while in MEDARVA Healthcare facilities, either in person or in writing.

As a parent or legal guardian, I affirm that I will reinforce the need for complete privacy for patient information with my student and understand that any breach of this federal regulation will result in dismissal from the MEDARVA Scholars program without renumeration.

I recognize that there is an element of risk in any out of home settings, including the MEDARVA Foundation’s Scholars program. My child may be exposed to physical hazards, emotional demands, communicable diseases, or other unanticipated events. By signing below, I authorize my minor child to participate and on my child’s behalf I assume all risks of my child’s participation in this program. I hereby release and agree to hold harmless, the MEDARVA Foundation, MEDARVA Healthcare, MEDARVA Surgery Centers and MEDARVA Imaging, its employees, agents, officers, and directors and all volunteers from all liability, loss or damage, action, claims, and demands which now have or which may hereafter arise from my child’s participation in the routine activities of the MEDARV Foundation’s Scholars program. This release is intended to be binding up on my heirs, executors, or personal representatives. I hereby certify that my child is in normal health, and to my knowledge, is capable of participating safely in this program. Should any injury occur to my child during participation in the MEDARVA Foundation Scholars program, I authorize MEDARVA Healthcare representatives to arrange for or to provide emergency medical treatment and to arrange for or provide transportation to the nearest qualified medical facility. I give MEDARVA Healthcare and medical treatment staff and personnel permission to administer to my child should my child be injured while attending program activities. I also understand that MEDARVA Healthcare does not carry medical insurance for my child, and it is my responsibility to pay all bills associated with such action. I give my child permission to use MEDARVA Foundation computers and to access the internet appropriately for educational purposes.
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.