Changing lives, One student at at time
CDE Career Institute (CDE) offers a Phlebotomy Techniclan Program ( "The Program"), designed to prepare students for employment as Phlebotomists. As part of the program, Phlebotomy Technician program students ("Phlebotomy Students") are trained to draw and collect blood samples. In order for students to complete this training, volunteers are needed. lf 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 forrn. Student volunteers must also have a Parent/ Guardian review and sign this form, unless the Student Volunteer is over 18 and no longer a dependant.
Informed Consent: By my signature below, I understand and agree as follows:
1. l have read the information provided in this form and had the opportunity to ask any questions I have.
2. I am providing my informed consent for the student Volunteer named below to participate as a volunteer in the program, by permitting a Phlebotomy Student to take a blood draw from the Student Volunteer under direct and close supervision of a program instructor.
3.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, l understand and agree as follows:
1. I voluntarily assume any and all risk relating to the Student Volunteer's participation as a Student Volunteer in the program.
2. I, my heirs, assigns and representatives herby release, waive, discharge, hold harmless, defend and indemnify CDE and/or the Program, their officers, agents, volunteers, and employees from any and all liablity, 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.
3. The Program cannot be expected to control all the risk associated with this Proqram 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 cost of treatment.
4. I have read this consent and Waiver and Release of Liability form, understand it and sign it voluntarily.