Raven EMS Education Program Manual
Policy Manual Acknowledgement Form

Student’s name:

My signature below indicates that I have received, read, and understood the policy manual and class syllabus. I agree to follow and adhere to the guidelines set forth by the policy manual, class syllabus, and the instructors. I have received, read, and understood the clinical requirements for the course I am enrolling in. I agree to follow and adhere to the guidelines set forth by each course and clinical site. I understand that my final grade will be impacted by my actions or my inactions. I understand that my success or lack thereof is solely my responsibility and not that of the faculty or staff. I take full responsibility for myself and my actions.

As a student, I understand that my performance will be evaluated by faculty, instructors, preceptors, FTOs, and clinical educators in cognitive, psychomotor, and affective domains. I will be informed of the content of these evaluations.

Safety is required of all students. The following are grounds for course failure and may result in dismissal from the course:

• Preceptor, FTO, or clinical educator refusal to continue working with the student due to clinical safety issues.
• Behavior during educational activities that indicates impaired judgment and/or unfit condition for the learning environment.
• Abuse or inappropriate behavior.
• Patient neglect.
• Breach of patient confidentiality (HIPAA).
• Dishonesty with the patient or own actions.
• Refusal to follow directions or commands given by preceptors, FTOs, instructors, faculty, or clinical educators that are meant to ensure your safety, other responder’s safety, or patient safety.
• Other unsafe clinical practice as deemed by faculty.

You are enrolling in the following program: Start date:

Your deadlines are listed below. Exceptions are only granted on EXTREMELY extenuating circumstances on a case-by-case basis as long you have been making progress towards goals up until the circumstance (i.e. immediate family lengthy medical crisis, military deployment, etc.). Upon unsuccessfully completing the required activity by the dates below, immediately after that date, you will be listed as “did not complete the program” on NREMT.org and will be unable to take the registry computer-based test or other licensure requirement (if applicable).

By signing below, I acknowledge that I have read, understood, and agree to all the above.

Student’s signature:
Clear

Instructor’s signature:
Clear

	Relevant. Resolute. Ready.
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