Course Orientation Page

Please review the orientation powerpoint for the program that was attached to the email you received. Please review all documents in detail.

Check off each box after you review and understand each document listed.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Confirm Email

Phone *

What class are you taking? *

Please choose which class you are enrolled in.

Check off documents that have been reviewed. *

Student Handbook
Release of Liability
Multi-Media Consent Form
Immunization Requirements
Student Profile Sheet
Allergy Form
Sexual Harassment Policy
IGW Agreement
Acknowledgement Form
Fraternization Policy
Contact Information
NNAAP Reference Sheet
HIPAA Reference Sheet
HIPAA Competency Exam
Practical Skills Performance Sheet
Clinical Rubric
Course Syllabus
Course Textbooks
Course Workbooks

Please check the boxes only if you have reviewed and understood each document in detail.

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Do you take daily medications? *

Do you have Medication or Food allergies? *

Please choose

Please list your daily medications. *

(Rx meds only) Should something happen to you, this vital information will be given to EMS.

What are your allergies? *

Please list all Food and Medication allergies.

Signature *

I have read, understood and will comply with all the polices listed above. I have answered any questions asked, truthfully. Please accept this signature as a signature for all documents listed on this check-list.

Phone

IGW and American Safety Programs financing terms and conditions page.

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