Common use of DECLARATION OF INTENT Clause in Contracts

DECLARATION OF INTENT. First Coast Technical College’s mission is to provide career, technical, & adult education to meet the changing needs of students, businesses, & the workforce. We expect that our students will attain certification and/or licensure appropriate for their field. However, there are times when students enroll in our career courses for reasons other than certification and/or employment. In that case, students must declare his or her intent to enroll for personal reasons, waiving their commitment to attain certification and/or licensure. If you DO NOT PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled for personal enrichment. ☐ I plan to work as volunteer or as a hobby. ☐ I plan to continue my education at another college or university. Student Name: Print Please Student’s Signature: Date: If you DO PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled to attain certification and become employed. Student Name: Print Please Student’s Signature: Date: Complete the form below taking care to address all areas. This signature page will be kept in each student’s file in the Medical Assisting Department. I HAVE RECEIVED A COPY OF THE FCTC MEDICAL ASSISTING STUDENT HANDBOOK AND I AM PERSONALLY RESPONSIBLE FOR THE INFORMATION CONTAINED THEREIN. I, (student name) , have carefully read and studied the Medical Assisting Student Handbook and Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. I, (student name) , agree or do not agree to FCTC releasing school attendance, grades, competency information , health and/or background information to a potential employer, federal, state or local government agency. I, (student name) , do or do not authorize emergency medical care. I agree , I do not agree FCTC may use my photo, likeness, and or name in school publications or periodicals for such purposes as advertising and media releases. I, (student name) , understand that the extern/practicum schedule will include longer hours, daytime hours and travel depending on the site in which the rotation occurs. I, (student name) , understand that lab remediation experience outside of classroom time may be assigned in the medical assisting lab. I, (student name) , willingly consent to participate in all laboratory treatments and practice sessions as a human subject (i.e., patient) for educational purposes at First Coast Technical College. These treatments may be rendered by faculty or by fellow students. It is my responsibility to disclose any information or medical issues that will limit or bar me from the above participation to the Program Coordinator or Instructor in a timely manner. FCTC Principal’s Signature Date FCTC CTE Director Signature Date Health Career Coordinator’s Signature Date Student’s Signature Date PARENT/GUARDIAN RESPONSIBILITY (Required if student is less than 18 years of age). I, as the parent/guardian, have carefully read and studied the Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. Parent/Guardian’s Signature Date

DECLARATION OF INTENT. First Coast Technical College’s mission is to provide career, technical, & adult education to meet the changing needs of students, businesses, & the workforce. We expect that our students will attain certification and/or licensure appropriate for their field. However, there are times when students enroll in our career courses for reasons other than certification and/or employment. In that case, students must declare his or her intent to enroll for personal reasons, waiving their commitment to attain certification and/or licensure. If you DO NOT PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled for personal enrichment. ☐ I plan to work as volunteer or as a hobby. ☐ I plan to continue my education at another college or university. Student Name: Print Please Student’s Signature: Date: If you DO PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled to attain certification and become employed. Student Name: Print Please Student’s Signature: Date: Complete I have reviewed the form below taking care to address all areas. This signature page will be kept in each student’s file in FCTC Dental Assisting Student Handbook and I am personally responsible for the Medical Assisting Department. I HAVE RECEIVED A COPY OF THE FCTC MEDICAL ASSISTING STUDENT HANDBOOK AND I AM PERSONALLY RESPONSIBLE FOR THE INFORMATION CONTAINED THEREINinformation contained therein. I, (student name) , have carefully read and studied the Medical Dental Assisting Student Handbook and Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. I, (student name) , agree or do not agree to FCTC releasing school attendance, grades, competency information , health and/or background information to a potential employer, federal, state or local government agency. I, (student name) , do or do not authorize emergency medical care. I agree , I do not agree FCTC may use my photo, likeness, and or name in school publications or periodicals for such purposes as advertising and media releases. I, (student name) , understand that the extern/practicum extern schedule will include longer hours, daytime hours and travel depending on the site in which the rotation occurs. I, (student name) , ,understand that lab remediation experience outside of classroom time may be assigned in the medical assisting dental lab. I, (student name) , willingly consent to participate in all laboratory treatments and practice sessions as a human subject (i.e., patient) for educational purposes at First Coast Technical College. These treatments may be rendered by faculty or by fellow students. It is my responsibility to disclose any information or medical issues that will limit or bar me from the above participation to the Program Coordinator or Instructor in a timely manner. FCTC Principal’s Signature Date FCTC CTE Director Signature Date Health Career Coordinator’s Specialist Signature Date Student’s Signature Date PARENT/GUARDIAN RESPONSIBILITY (Required if student is less than 18 years of age). I, as the parent/guardian, have carefully read and studied the Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. Parent/Guardian’s Signature Date

DECLARATION OF INTENT. First Coast Technical College’s mission is to provide career, technical, & adult education to meet the changing needs of students, businesses, & the workforce. We expect that our students will attain certification and/or licensure appropriate for their field. However, there are times when students enroll in our career courses for reasons other than certification and/or employment. In that case, students must declare his or her intent to enroll for personal reasons, waiving their commitment to attain certification and/or licensure. If you DO NOT PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled for personal enrichment. ☐ I plan to work as volunteer or as a hobby. ☐ I plan to continue my education at another college or university. Student Name: Print Please Student’s Signature: Date: _ If you DO PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled to attain certification and become employed. Student Name: Print Please Student’s Signature: Date: Complete the form below taking care to address all areas. _ This signature page will be kept in each student’s online file in the Medical Assisting DepartmentFOCUS. I HAVE RECEIVED A COPY OF THE FCTC MEDICAL ASSISTING NURSING STUDENT HANDBOOK AND I AM PERSONALLY RESPONSIBLE FOR THE INFORMATION CONTAINED THEREIN. I, (student name) , have carefully read and studied the Medical Assisting Nursing Student Handbook and Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. I, (student name) , agree or do not agree to FCTC releasing school attendance, grades, competency information , health and/or background information to a potential employer, federal, state or local government agency. I, (student name) , do or do not authorize emergency medical care. I agree , I do not agree FCTC may use my photo, likeness, and or name in school publications or periodicals for such purposes as advertising and media releases. I, (student name) , understand that the extern/practicum clinical schedule will include longer hours, daytime hours and travel depending on the site course in which the clinical rotation occurs. I, (student name) , ,understand that lab remediation experience outside of classroom time may be assigned in the medical assisting nursing lab. I, (student name) , willingly consent to participate in all laboratory treatments and practice sessions as a human subject (i.e., patient) for educational purposes at First Coast Technical College. These treatments may be rendered by faculty or by fellow students. It is my responsibility to disclose any information or medical issues that will limit or bar me from the above participation to the Program Coordinator Specialist or Instructor in a timely manner. FCTC Principal’s Signature Date FCTC CTE Director Signature Date Health Career Coordinator’s Specialist Signature Date Student’s Signature Date PARENT/GUARDIAN RESPONSIBILITY (Required if student is less than under 18 years of age). I, as the parent/guardian, have carefully read and studied the Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. Parent/Guardian’s Signature Date

DECLARATION OF INTENT. First Coast Technical College’s mission is to provide career, technical, & and adult education to meet the changing needs of students, businesses, & and the workforce. We expect that our students will attain certification and/or licensure appropriate for their field. However, there are times when students enroll in our career courses for reasons other than certification and/or employment. In that case, students must declare his or her intent to enroll for personal reasons, waiving their commitment to attain certification and/or licensure. If you DO NOT PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled for personal enrichment. ☐ I plan to work as volunteer or as a hobby. ☐ I plan to continue my education at another college or university. Student Name: Print Please Student’s Signature: Date: If you DO PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled to attain certification and become employed. Student Name: Print Please Student’s Signature: Date: Complete the form below taking care to address all areas. This signature page will be kept in each student’s file in the Medical Assisting Department. I HAVE RECEIVED A COPY OF THE FCTC MEDICAL ASSISTING STUDENT HANDBOOK AND I AM PERSONALLY RESPONSIBLE FOR THE INFORMATION CONTAINED THEREIN. I, (student name) , have carefully read and studied the Medical Dental Assisting Student Handbook and Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. I, (student name) , agree or do not agree to FCTC releasing school attendance, grades, competency information , health and/or background information to a potential employer, federal, state or local government agency. I, (student name) , do or do not authorize emergency medical care. I agree , I do not agree FCTC may use my photo, likeness, and or name in school publications or periodicals for such purposes as advertising and media releases. I, (student name) , understand that the extern/practicum extern schedule will include longer hours, daytime hours and travel depending on the site in which the rotation occurs. I, (student name) , understand that lab remediation experience outside of classroom time may be assigned in the medical assisting dental lab. I, (student name) , willingly consent to participate in all laboratory treatments and practice sessions as a human subject (i.e., patient) for educational purposes at First Coast Technical College. These treatments may be rendered by faculty or by fellow students. It is my responsibility to disclose any information or medical issues that will limit or bar me from the above participation to the Program Coordinator Health Careers Specialist or Instructor in a timely manner. FCTC Principal’s Signature Date FCTC CTE Director Signature Date Health Career Coordinator’s Specialist Signature Date Student’s Signature Date PARENT/GUARDIAN RESPONSIBILITY (Required if student is less than 18 years of age). I, as the parent/guardian, have carefully read and studied the Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. Parent/Guardian’s Signature Date

DECLARATION OF INTENT. First Coast Technical College’s mission is to provide career, technical, & technical and adult education to meet the changing needs of students, businesses, & businesses and the workforce. We expect that our students will attain certification and/or licensure appropriate for their field. However, there are times when students enroll in our career courses for reasons other than certification and/or employment. In that case, students must declare his or her intent to enroll for personal reasons, waiving their commitment to attain certification and/or licensure. If you DO NOT PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled for personal enrichment. ☐ I plan to work as volunteer or as a hobby. ☐ I plan to continue my education at another college or university. Student Name: Print Please Student’s Signature: Date: If you DO PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled to attain certification and become employed. Student Name: Print Please Student’s Signature: Date: Complete the form below taking care to address all areas. This signature page will be kept in each student’s file in the Medical Assisting Department. I HAVE RECEIVED A COPY OF THE FCTC MEDICAL ASSISTING STUDENT HANDBOOK AND I AM PERSONALLY RESPONSIBLE FOR THE INFORMATION CONTAINED THEREIN. I, (student name) , have carefully read and studied the Medical Assisting Student Handbook and Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. II agree , (student name) , agree or I do not agree to FCTC releasing school attendance, grades, competency information , health and/or background information to a potential employer, federal, state or local government agency. II authorize , (student name) , do or I do not authorize emergency medical care. I agree , I do not agree that FCTC may use my photo, likeness, and or name in school publications or periodicals for such purposes as advertising and media releases. II understand , (student name) , I do not understand that the extern/practicum clinical schedule will include longer hours, daytime hours and travel depending on the site course in which the clinical rotation occurs. II understand , (student name) , I do not understand that lab remediation experience outside of classroom time may be assigned in the medical assisting lab. II willingly , (student name) , I do not willingly consent to participate in all laboratory treatments and practice sessions as a human subject (i.e., patient) for educational purposes at First Coast Technical College. These treatments may be rendered by faculty or by fellow students. It is my responsibility to disclose any information or medical issues that will limit or bar me from the above participation to the Program Coordinator Specialist or Instructor in a timely manner. FCTC Principal’s Health Career Specialist Signature Date FCTC CTE Director Signature Date Health Career Coordinator’s Signature Date Student’s Student Signature Date PARENT/GUARDIAN RESPONSIBILITY (Required required if student is less than under 18 years of age). I, as the parent/guardian, have carefully read and studied the Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. Parent/Guardian’s Signature (required if under 18 years of age) Date

DECLARATION OF INTENT. First Coast Technical College’s mission is to provide career, technical, & adult education to meet the changing needs of students, businesses, & the workforce. We expect that our students will attain certification and/or licensure appropriate for their field. However, there are times when students enroll in our career courses for reasons other than certification and/or employment. In that case, students must declare his or her intent to enroll for personal reasons, waiving their commitment to attain certification and/or licensure. If you DO NOT PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled for personal enrichment. ☐ I plan to work as volunteer or as a hobby. ☐ I plan to continue my education at another college or university. Student Name: Print Please Student’s Signature: Date: If you DO PLAN to work in this field: Please complete the information below, indicating your reason for enrolling in this program: ☐ I enrolled to attain certification and become employed. Student Name: Print Please Student’s Signature: Date: Complete the form below taking care to address all areas. This signature page will be kept in each student’s file in the Medical Dental Assisting Department. I HAVE RECEIVED A COPY OF THE FCTC MEDICAL ASSISTING STUDENT HANDBOOK AND I AM PERSONALLY RESPONSIBLE FOR THE INFORMATION CONTAINED THEREIN. I, (student name) , have carefully read and studied the Medical Dental Assisting Student Handbook and Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. I, (student name) , agree or do not agree to FCTC releasing school attendance, grades, competency information , health and/or background information to a potential employer, federal, state or local government agency. I, (student name) , do or do not authorize emergency medical care. I agree , I do not agree FCTC may use my photo, likeness, and or name in school publications or periodicals for such purposes as advertising and media releases. I, (student name) , understand that the extern/practicum extern schedule will include longer hours, daytime hours and travel depending on the site in which the rotation occurs. I, (student name) , ,understand that lab remediation experience outside of classroom time may be assigned in the medical assisting dental lab. I, (student name) , willingly consent to participate in all laboratory treatments and practice sessions as a human subject (i.e., patient) for educational purposes at First Coast Technical College. These treatments may be rendered by faculty or by fellow students. It is my responsibility to disclose any information or medical issues that will limit or bar me from the above participation to the Program Coordinator or Instructor in a timely manner. FCTC Principal’s Signature Date FCTC CTE Director Signature Date Health Career Coordinator’s Signature Date Student’s Signature Date PARENT/GUARDIAN RESPONSIBILITY (Required if student is less than 18 years of age). I, as the parent/guardian, have carefully read and studied the Training Contract Agreement and by my signature, agree to abide by the policies and regulations with the understanding this is a condition of acceptance and continuance in the program. Parent/Guardian’s Signature Date