Student Information

Student Name

First NameLast Name

Student Email

example@example.com

Do you have any medical history?*

YesNo

If yes, please list all your medical history.

Are you currently prescribed any medication?*

YesNo

If yes, please list any current medication.

Do you have any allergies to medications, foods, or environmental factors?*

YesNo

If yes, please list all allergies.

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Emergency Contact Relationship*

Have you ever been arrested?*

YesNo

If yes, were you convicted of a misdemeanor or a felony?*

YesNo

If yes, please explain.

Authorization To Use For Publicity and/or Advertisement Purposes*

I DO AUTHORIZE my name, photograph, videos of myself, and statements made by me to be released by Trinity EMS Academy, LLC for publicity and/or advertisement purposes.I DO NOT AUTHORIZE my name, photograph, videos of myself, and statements made by me to be released by Trinity EMS Academy, LLC for publicity and/or advertisement purposes.

NOTICE & INSTRUCTIONS: As a current or former student, the information contained in your education records at Trinity EMS Academy is protected by a Federal privacy law known as the Family Educational Rights and Privacy Act (FERPA). Except under limited exceptions specified in FERPA, school officials can only share your education records or discuss information from your records with third parties if you provide "prior written consent" - that is, your explicit permission in writing.

There may be times when you want to share certain education records and information with someone external to the Academy. Academy officials may require you to provide prior written consent by completing this form before they release the specified records or information.

Please note that this consent may be revoked at anytime by providing written notice of such revocation to the Academy official to whom this form was originally submitted. The revocation will apply only to prospective requests for records. The Academy reserves the right to require a student to submit a new or updated form as needed.

Name and Relationship: Please list any individuals, and their relationship to you, such as "potential employers", "mother or father", "anyone", etc. If you do not wish to include anyone on this FERPA Authorization to Release Information, please enter NONE. You may change this at any time by contacting your instructor or a staff member in writing. *

I understand this Authorization to Release Information remains in effect until I revoke its authorization in writing. I have carefully read the statements above and fully understand the meaning of this FERPA Authorization to Release Information. I affirm that I have signed this authorization voluntarily.*

I understand that I will be performing venipuncture, capillary puncture, and various types of injections on other students, and that other students will be performing these procedures on me. I understand that this practice is necessary to gain practical, firsthand experience in performing these procedures. Classroom theory will be presented and the risks fully explained to me before this occurs. I understand there is always a risk, although remote, of a break in sterile technique and a risk of contracting an infectious disease such as HIV or Hepatitis B. I also understand that there is some risk of a hematoma, or bleeding in the tissue, as a result of the invasive procedure. I understand the risks, and freely and voluntarily agree to participate in the procedure. I hereby release Trinity EMS Academy and its instructors from any and all liability as a result of my participation in these procedures.*

In consideration of being allowed to participate in any training, events and activities associated with Trinity EMS Academy's courses, I, the undersigned, acknowledge, appreciate and agree that:

1. The risk of injury from the training, events and activities involved in this program is possible, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist.

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM NEGLIGENCE OF THE RELEASE ES (as defined below) or others, and assume full responsibility for my participation in the program.

3. Despite such risks, I willingly agree to participate in the program and comply with the terms and conditions for participation in the program, which I acknowledge receiving from Trinity EMS Academy and understand completely. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and will notify Trinity EMS Academy of such hazard immediately.

4. I certify that I am physically and mentally fit to participate in this program and have not been advised by a qualified medical professional not to participate in this program. I certify that there are no health-related reasons or problems which preclude my participation in this activity or event and have disclosed any underlying medical conditions to Trinity EMS Academy.

5. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during my participation in the program. I agree that I will not hold the releasees responsible for any claims resulting from any medical treatment I receive.

6. I RELEASE, WAIVE, AND DISCHARGE ANY AND ALL CLAIMS that I or my heirs, assigns, personal representatives, and next of kin, may have now or in the future against Trinity EMS Academy, and its trustees, officers, directors, employees, representatives, agents, affiliates, insurers, successors and assigns; other participants, sponsors, and advertisers of the program; and, if applicable, owners and lessors of the premises used for the program (collectively the "Releasees") for any liability, expenses, loss or damage to person or property, injury, death or disability suffered from or in connection with my presence or participation in the Program due to any cause whatsoever, INCLUDING THE NEGLIGENCE ON THE PART OF THE RELEASEES. I HEREBY AGREE NOT TO SUE OR MAKE CLAIMS AGAINST THE RELEASE ES AND GIVE UP ALL MY RIGHTS TO DO
so.

7. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY, DEFEND AND HOLD HARMLESS the Releasees, WITH RESPECT TO ANY AND ALL LIABILITY, INJURY, DISABILITY, DEATH or loss or damage to person or property, or expenses or fees (including reasonable attorney's fees) associated with my presence or participation in the Program, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

8. If any provision of this Release of Liability, or the application of such provision, shall be rendered or declared invalid by a court of competent jurisdiction, or by reason of its requiring any steps, actions or results, the remaining parts or portions of this Release shall remain in full force and effect.

I HAVE READ THIS WAIVER OF LIABILITY AND FULLY UNDERSTAND THEIR TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. MY SIGNATURE BELOW FURTHER INDICATES THAT THE INFORMATION I HAVE PROVIDED ON THE APPLICATION FOR ADMISSION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. *

My signature below indicates I have read and understand the information contained in this Registration Packet. If I have questions, I understand I may contact the office at 706-940-0186.*

Date Signed*

Date

Student Information

Medical Information

Emergency Contact Information

Background Information

Audio / Visual Agreement

Family Educational Rights and Privacy Act (FERPA)

Student's Authorization to Release Information

Release and Waiver of Liability For Venipuncture

General Waiver of Liability