Clinical Ride Time Student Waiver

By my signature below, I have read and understand my training program's policies concerning field internship and agree to abide by them.Further, I agree to follow all rules and regulations promulgated by any State's Office of EMS or Bureau of EMS regarding field internship and agree to work within my scope of practice, following appropriate state and regional protocols, while under the direct observation and control of my designated preceptor. I understand that AMR, Great Brook Academy, or any other EMS or Fire based service that I am participating in clinical with may discontinue my internship at anytime, for any reason, upon notification of my training program.

An Affiliation Agreement exists between American Medical Response of Massachusetts,Incorporated and an EMS education program conducted and administered by the institutionnamed herein. The purpose of the Affiliation Agreement is to provide qualified students, duly enrolled in the aforementioned program, with a field internship experience and clinical practicumappropriate to their course of study.As a student enrolled in said program, I hereby acknowledge that any information that is learned or is generated as a result of my training activities, including information regarding patients orbusiness activities of AMR shall remain confidential. The only information that I may retain is that which verifies the successful completion of skills requisite to my course of study and said information shall have patient identifiers removed.I understand that the mandates for confidentiality are imposed by the US Health Insurance Portability and Accountability Act of 1996 (HIPAA); the US Privacy Act of 1974; applicable state laws; and that violations of confidentiality may be deemed a criminal offense.