STUDENT VOLUNTEER INFORMED CONSENT AND WAIVER AND RELEASE OF LIABILITY

Northeast Medical Institute (NEMI) offers a Phlebotomy Tech Program ("the Program"), designed to prepare students for immediate employment as a Phlebotomists and further college medical assistant education.

As part of the Program, Phlebotomy Tech Program students are trained to draw and collect blood samples. In order for students to complete this training, volunteers are needed.

If you are willing to be a Student Volunteer, please carefully review the information below and sign and date where indicated at the end of the form.

Important Information Regarding the Student Volunteer Experience

The Program involves learning to draw and collect blood samples.

After a NEMI Student has developed a level of expertise in drawing fluid from inanimate objects and with the use of training tools, he/she must develop expertise by practicing drawing blood from a

All blood draws taken by NEMI Students occur under the direct and close supervision of a Program instructor.

When drawing blood, the NEMI Student will wear gloves and use a sterile needle, rubbing alcohol (70% isopropyl) or 2% iodine tincture to ensure the site of the puncture is protected from bacteria. A tourniquet will then be applied. These steps are taken for the safety of the Student Volunteer and to

Following the blood draw, Student Volunteers are provided with a sterile gauze pad to enable the Student Volunteer to apply pressure to the site to lessen potential bruising. An adhesive strip will then be applied to hold the sterile gauze pad in place, thus maintaining the pressure once the puncture site has stopped bleeding.

Possible side effects during and/or immediately after the blood draw may include light-headedness, dizziness, localized pain, bruising and/or minor swelling around the puncture site.

Student Volunteers are encouraged to drink water or other fluids the day before and the day of the practice blood draw to assist the blood draw by ensuring that the volunteer's veins are fully hydrated.

Informed Consent: By my signature below, I understand and agree as follows:

I have read the information provided in this form and had the opportunity to ask any questions I have.

I am providing my informed consent for the Student Volunteer named below to participate as a volunteer in the Program, by permitting a NEMI Student to take a blood draw from the Student Volunteer under the direct and close supervision of a Program instructor.

The Student Volunteer named below has no medical conditions that would be adversely impacted by his/her volunteer participation in the Program.

Waiver of Liability and Release of Claims: By my signature below, I understand and agree as follows:

I voluntarily assume any and all risks relating to the Student Volunteer's participation as a Student Volunteer in the Program.

I, my heirs, assigns and representatives hereby release, waive, discharge, hold harmless, defend and indemnify NEMI and/or the Program, their officers, agents, volunteers, and employees from any and all liability, claims, demands, damages, fees or expenses, or actions whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by the Student Volunteer as a result of the Student Volunteer's participation in the Program.

The Program cannot be expected to control all of the risks associated with this Program and that there may be the need for a response to accidents and potential emergencies. Therefore, I give my consent for any medical treatment that may be required as determined by a medical professional during the Student Volunteer's participation as a volunteer in the Program, with the understanding that I will be financially responsible for all costs of treatment.

I have read this Consent and Waiver and Release of Liability form, understand it and signit voluntarily.

Please contact Daniel Remiszewski, the owner of Northeast Medical Institute, if you have any questions regarding this volunteer opportunity or this form. Thank you!