Vocational

I give Genesis Medical College permission to print the following information with school administrators, staff, and other students. This information is only to be shared internally for program purposes. I understand it is my responsibility to keep contact information current by reporting any changes in my student account.

• Name
• Phone number
• Email address

By entering my electronic signature below, I agree to have my information shared.

Sign below to give permission to use your image in photo and video.

Permission is required to participate in an hybrid or 100% online program or course. GMC takes photos of students for attendance and records lectures for regulatory compliance. This is an essential part of the hybrid class. Cameras must include the face displayed and the ability to demonstrate online skills If this is not acceptable, please contact GMC as soon as possible.

I hereby give my permission to Genesis Medical College to use any photos or videotape material taken of myself during any courses taught, training sessions, and/or staff functions. The photos and videotape material may or may not be used, but remain the property of GMC. Any photos or videos will be used for internal business purposes, internal or external training purposes, and/or for marketing purposes. As with all consent, I may at any time withdraw permission for photos or video footage of me to be used.

*Your permission is required to participate in the class. 
*Your enrollment may be impacted if you do not give permission. 

By entering my electronic signature below, I agree to the use of my photograph or videotape.

The discussions, uses, and disclosures addressed by this agreement apply to any written, verbal, or electronic communications.

I understand that I am never to discuss or review any information regarding a patient at a clinical site unless the discussion or review is part of my assignment to the site. I understand that I am obligated to know and adhere to the privacy policies and procedures of the clinical site to which I am assigned. I acknowledge that medical records, accounting information, patient information, and conversations between or among healthcare professionals about
patients are confidential under law and this agreement.

I understand that, while in the clinical setting, I may not disclose any information about a patient during the clinical portion of my clinical assignment to anyone other than the medical and nursing staff of the clinical site.

I understand that I may not remove any record from the clinical site without the written authorization of the site. Additionally, I understand that, before I use or disclose patient information in a learning experience, classroom, case presentation, class assignment, or research, I must attempt to exclude as much of the following information as possible:

• Names
• Geographical subdivisions smaller than a state
• Dates of birth, admission, discharge, and death
• Telephone numbers
• Fax numbers
• E-mail addresses
• Social security numbers
• Medical record numbers
• Health plan beneficiary numbers
• Account numbers
• Certificate/license numbers
• Vehicle identifiers
• Device identifiers
• Web locators (URLs)
• Internet protocol addresses
• Biometric identifiers
• Full face photographs
• Any other unique identifying number, characteristic, or code
• All ages over 89 years

Additionally, I acknowledge that any patient information, whether or not it excludes some or all
of those identifiers, may only be used or disclosed for health care training and educational
purposes, and must otherwise remain confidential.

I understand that I must promptly report any violation of the clinical site’s privacy policies and
procedures, applicable law, or this confidentiality agreement, by me, or a student or faculty
member to the appropriate clinical coordinator or program director.

Finally, I understand that, if I violate the privacy policies and procedures of the clinical site,
applicable law, or this agreement, I will be subject to disciplinary action.

By entering my electronic signature below, I certify that I have read and understand its terms and will comply with them.

Candidates for the program that require a clinical skills component must have certain essential skills and functional abilities. If a candidate believes that he or she does not possess one or more of these skills or abilities without accommodations, then GMC must determine, on an individual basis, whether a reasonable accommodation can be made. Essential skills and abilities are performance requirements required for satisfactory completion of a GMC healthcare program. The essential skills required by the curriculum areas are listed below.

Essential Abilities Requirements for Promotion and Retention Signature

I have read the information, watched the video, and have had the opportunity to have all of my questions answered regarding the Essential Skills and Functional Abilities. My signature represents that I understand and will abide by these requirements.

PREGNANCY: If you are known to be pregnant, you must obtain and present a medical release signed by your physician to participate in the live testing portion of this course. You may also bring an eligible proxy to be tested upon in your place.

1. The drawing of blood will only occur in the phlebotomy lab, under the observation of the course instructor, or at the clinical site.


2. Instructors will observe the daily distribution, use and return of sharps.


3. Each student will have their own individual sharps container with their name on it.


4. A student may not leave the lab area with any sharps item (needles, winged infusion sets) syringes, tubes empty or filled with blood.


5. Students will return their individual sharps container to the instructor with used blooddrawing equipment before the end of class.


6. Student will not leave the class until all lab equipment is accounted for.


7. All sharps, sharps containers, blood collection tubes will be kept in a secure area.

1. Student or parent/student conference


2. Campus probation


3. Removal from program’