IMDT Enrollment Agreement

The Institute of Medical and Dental Technology

5280 Summerlin Commons Way Suite #804

Fort Myers, FL 33907

(239) 208-7290

COURSE INFORMATION:

Course Name: Program Name:

Admission Representative:

STUDENT INFORMATION:

Full Name:

Street Address:

City: State:

Phone Number:

E-Mail Address:

Social Security Number:

Birth Date:

Emergency Contact Name:

Emergency Contact Phone Number:

Canvas Start Date:

Skills Start Date:

Program Anticipated End Date:

Program Type: Certificate Delivery Method: Campus

Total Clock Hours: 288 Total Weeks: 16

SCHOLARSHIP:

Scholarship Type: Institutional Scholarship

Scholarship Amount: $

By initialing below you are accepting the scholarship(s) awarded and understand any and all scholarships provided by IMDT are based off of individual qualifications at the time of application and are between the recipient and said institution.

Initial:

By initialing below you are acknowledging you have read the and understand this agreement and acknowledge receipt of a copy. You understand the awarded scholarship cannot be transferred to another institution or person and some may only apply to certain offered programs. You are also required to maintain full time enrollment and minimal academic standards per the student catalog. You understand that if you default upon this agreement, the awarded scholarship will be revoked and you will be responsible for any and all fees set by any and all financial lenders.

Initial:

PAYMENT INFORMATION:

Method of Payment:

Program Cost:

Please Choose one of the Following:

Please Fill out the following if applicable:

Annual Percentage Rate:%	Finance Charge: $	Amount Financed (the dollar amount the credit provided to you on your behalf): $	Total of Payment (the amount you will have paid after you have made all payments as scheduled): $	Total Sales Price (the total cost of your purchase on credit including your down payment): $

You Payment Schedule will be:

Number of Payments:	Amount of Each Payment: $	Payments are due: Beginning on and on the same day each (select one) thereafter

ADDITIONAL PROGRAM FEES NOT INCLUDED IN TUITION
Textbook/eBooks Average $ (estimated)
Access Code & E-Book $
Name Tag $ cost varies (paid to school)
CPR, TB, Hep B & Uniform $ cost varies (estimated)
Online Technology Requirements $ cost varies (see catalog)
Dental Teeth Fee (If Applicable) $ 80 (paid to school)
Florida State Radiation Certification (If Applicable) $ 35 (paid to school)

ACCESS CODE ACKNOWLEDGMENT

Please Check ONE of the Follwing:

I have agreed to have my Access Code fee included in the Financing of my Tuition.

I have agreed to pay for the Access Code at the time of Enrollment.

If Access Code is included in Financing please select the amount:

I understand that if there are additional program fees not included in the tuition and that will be the responsibility of the student.

I understand that by signing and executing this agreement the Access Code Fee will no longer be refundable.

Please read this Enrollment Agreement thoroughly as you are agreeing to the following:

MEDIA POLICY:

I, Undersigned, do hereby give my consent and agree the IMDT employees have the right to take photographs, videotape, or digital recordings of me to use in any and all media outlets. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I understand there will be no financial or other forms of remuneration for any of the above, either for initial or subsequent transmission or playback. I represent I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

Initial:

OSHA STANDARDS:

To be in compliance with OSHA standards on bloodborne pathogens, each student must be informed of the mandatory Universal Precautions in all healthcare settings. These standards and precautions are included and covered in detail within the courses. This must be completed by the student prior to externship eligibility. It is also required that students be informed and encouraged to begin the Hepatitis B vaccine series. However, you may decline vaccination at this time. Students are required to read and sign the Hepatitis B Statement of Informed Consent prior to placement in an externship facility. Students will be required to meet all OSHA requirements on the externship. In addition, each individual facility may have some variation of these rules and regulations and it is the student’s responsibility to obtain a copy of these rules and regulations at that externship site. Those regulations set forth by that facility, must also be met by the student.

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STUDENT EXPOSURE INFORMATION:

IMDT students are responsible for:

Reading this student information sheet and following the guidelines.
Identifying the appropriate contacts on campus and at externship sites.
Paying for all expenses either through their own health insurance or other personal means associated with testing, medications, and related costs.
Providing medical expenses to include blood work requested of source patients.

If you experienced a needle stick or sharps injury or were exposed to the blood or other body fluid of a patient/student during the course of your extern/study, immediately follow these steps:

Wash needle sticks and cuts with soap and water
Flush splashes to the nose, mouth, or skin with water
Irrigate eyes with clean water or saline
Report the incident to your instructor
Refer to exposure control plan and fill out exposure report form
Students should have appropriate initial laboratory tests if needed per current CDC guidelines performed as soon as they can get and appointment but no later than the next business day

Students are not an employee of the school ; therefore, they are not eligible for worker’s compensation benefits (although they may be required to complete similar paperwork to document the details of the exposure). The student will be responsible for the cost of their care, either through their own health insurance or other personal means. All source patients are encouraged to have blood work as designated by the CDC protocol current at the present time (presently HCV antibody, HIV antibody, and Hepatitis B surface antigen). The student requesting the blood work may be held responsible for the cost of treatment for the source patient.

Students will be directed to have source patient information available for their discussion with the appropriate personnel at the outside facility, if available, concerning the exposure:

Approximate time of exposure
Location of exposure (e.g., school, medical or dental office, etc.)
Source of the exposure (e.g., blood, contaminated instrument, etc.)
Type of exposure (e.g., skin, mucous membrane percutaneous)
Length of exposure (e.g., seconds/minutes/hours)
Status of the source patient: Negative, Positive, or Unknown HIV, HBV, and HCV status
Whether or not patient is at risk for HIV,HBV, or HCV infection because of:
- Multiple blood transfusions 1978-1985
- IV drug user
- Multiple hetro- or homosexual partners
- Known HIV positive and/or have symptoms of AIDS, HBV or HCV
- Significant blood or bodily fluid exposure has occurred

IMDT will not be held responsible nor pay expenses incurred from student exposure, to include needle sticks. IMDT recommend students seek medical treatment if necessary and to follow the treatment protocol advised from the medical facility at the expense of the student. Students assume their responsibility upon enrollment as there are risks associated with study and employment in the healthcare field.

Initial:

STUDENT EXTERNSHIP CONFIDENTIALITY AGREEMENT

I will keep all patient information confidential. I will disclose patient information in accordance with the policies of the facility that I am assigned to during my student externship experience. Furthermore, I understand and agree to comply with the guidelines set forth by HIPAA.

I will not discuss any information, patient-related or relating to the operations of the facility to include my own health record if applicable. I will keep all security codes and passwords used to access the facility, equipment and computer systems confidential.

I will access or view patient information only as it is required in the scope of my student experience to include my own health record if applicable.

I will not disclose, copy, transmit, modify or destroy patient information or other confidential practice information without the permission of my supervisor or the practice’s privacy officer.

I agree to comply with these conditions even after my student externship experience is terminated.

I understand violation of this agreement may result in disciplinary action, up to and including termination from the externship and dismissal from my program. My signature on this agreement indicates that I, a student of IMDT have read, understand and will comply with all aspects of this confidentiality agreement.

Initial:

MISCONDUCT POLICY:

Students must adhere to conduct that will not interfere with the learning process of any other student, teacher,externship site, or the progress of the class in general. Those students whose conduct reflects discredit upon themselves or the school will be subject to immediate expulsion. The IMDT reserves the right to exercise judgment of a student and to terminate a student for any of the following reasons:

Breach of the school enrollment agreement, Failure to abide by the rules and regulations of any clinical site, Entering school grounds or externship site while under the influence of any type of, Alcohol or drugs , Possession of a dangerous or deadly weapon concealed or otherwise, Instigation, or participation in, rebellious activities against the school or its students, Solicitation which reflects unfavorably upon the school or its students, Failure to conform to the rules and regulations of the school, Conduct that reflects unfavorably upon the school or its students, Excessive absences or tardiness at campus or externship, Failure to pay charges when due, Cheating, Falsifying school records, Written or verbal profanity on campus/externship grounds, Vandalism of campus property, Disruptive classroom behavior, Physical threats of any nature, or Theft of any kind.

First Offense:
Behavior- The student is issued a written warning. A copy is kept in student’s file.
Academic- The student must redo or modify the assignment or exam at a 30% penalty, if student refuses to redo a zero will be earned.
Second Offense:
Behavior- The student must meet with the Program or Campus Supervisor to determine a course of action. A plan of action and/or incident report will be placed in student’s file.
Academic- The student will receive a zero on the item in question. No redo’s allowed.
Third Offense:
Behavior or Academic- The student will be expelled. Written documentation will be placed in student’s file.
When a student is determined to be guilty of academic or behavioral misconduct, the instructor will determine if a prior offense exists. Offenses accumulate during the students’ academic program(s). If prior incidents have occurred they will impact the current offense. Misconduct incidents may merit immediate expulsion and no warnings will be given, dependent on severity and outcome. IMDT strive to graduate only the upmost professional medical and dental assistants.

By signing this agreement you agree to having read and fully understand the expectations as a student at IMDT regarding misconduct.

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DRUG POLICY:

IMDT is committed to providing a safe and professional work environment for our students, volunteers, faculty and staff while on campus or at a clinical affiliation.

All students must be physically and mentally free of illegal drugs, alcohol, and prescription drugs that impair their intellectual and emotional functions. Some clinical affiliations (externships) require students to complete drug screening and/or a background check prior to clinical placement, or during if suspect of drug use. A positive drug screen may exclude you from clinical placement, graduation, and may warrant dismissal from the school.

Without exception, any student found in possession of these substances or a student is suspected of being under the influence of these substances (alcohol, illegal drugs, and prescription drugs) the Instructor and/or the Campus Supervisor will ask the student to leave the facility and immediately be drug tested at the student’s expense. Results are to be faxed directly to the instructor and must be received within 24 hours of being dismissed. The results will only be shared with the Instructor, Campus Supervisor and Education Director.

A positive test, failure or refusal to complete requested drug testing will result in automatic dismissal from the program. In the event of a positive test result, resources will be made available to the student to assist in counseling, treatment, or rehabilitation. Any student wishing to re-enroll after a positive drug screen or refusal to submit to testing must comply with an immediate drug screen upon admittance and is subject to random drug screening during their program at the student’s own expense. Any further positive test results or refusal will be cause for expulsion without option to re-enroll.

Initital:

HEPATITIS B VACCINATION & TUBERCULOSIS INFORMED CONSENT

By signing the agreement you are agreeing to the following:am currently enrolled as a Dental or Medical student at The Medical Institute of Kentucky/Choice MD/Institute of Dental Technology. I have been informed and understand that due to my possible exposure to blood and other potentially infectious substances, I may be at risk of acquiring TB, Hepatitis B, HIV infection or other infectious contagions.

I have been advised that vaccination for Hepatitis B is available through any local physician and is recommended by IMDT and the instructors therein. I understand that Hepatitis B is a serious disease.

I (medical student) have been advised that I am required to obtain TB testing before I may begin the skills portion of my medical education. Dental students have been advised that the school also recommends TB testing before beginning the skills portion of the dental program.

I have been given the opportunity to ask questions about inoculation and risks involved in receiving the vaccines and in declining vaccination. My questions have been answered to my satisfaction. I understand that IMDT is not responsible for my attaining vaccinations or liable in the event that I should contract any contagion during my education. I understand my externship site may request records before attendance, and I am responsible for obtaining them in a timely manner.

I have already been vaccinated or have started the Hep B series. I will supply proof of vaccination.

I do not plan to receive the Hep B vaccination at this time; however, I understand I may receive the vaccination at a later date. I will in inform the admissions department if I receive or plan to receive the series.

I have already been TB tested (within 6 months) or plan to receive before the first week of class. I will supply proof.

I (dental student) do not plan to obtain TB testing at this time, I understand I may obtain at a later date.

(Any late fee payments and conditions thereof must be disclosed on the enrollment agreement and in the catalog)

All prices for program are printed herein. Contracts are not sold to a third party at any time. There are no carrying charges, interest charges, or service charges connected or charged with any of these programs unless stated.

CANCELLATION AND REFUND POLICY

Student must provide written notice of cancellation/withdrawal by certified mail, to include: name, date, program enrolled, campus location and reason for cancellation to:

ATTN: Cassie Black, Operations Manager

2704 Old Rosebud Rd, Suite 130

Lexington, KY 40509

Program Cancellation:

The school may cancel a program at its discretion. Should this occur, any students enrolled prior to cancellation, will be notified of this change and will have the option of applying all monies paid toward another program or receiving a refund of all tuition paid within 45 days of the cancellation date.

Cancellation:

An applicant, who provides electronic submission or certified letter of cancellation after executing the enrollment agreement, but prior to the digital orientation of the program, is entitled to a full refund of all paid tuition. Unless they have been offered or secured employment in the field as a result of enrollment. Student has six months from enrollment date to seek any refunds of paid tuition. All refunds will be made within 45 days of the written notice receipt.

Withdrawal Procedure:

A. Students choosing to withdraw from a program after the digital orientation date are required to provide written notice of withdrawal as required above (attendance will be calculated until electronic submission or certified letter is received) and advised to meet with the On-site Administrator to complete an exit interview. The purpose of the exit interview is to assess the academic and financial status of the student.

B. Institute of Medical and Dental Technology has selected three consecutive weeks with no activity of academic requirements, without prior administrative approval, as the unofficial date which a student is deemed to have withdrawn. Students have six months from the last attended date to request a refund of monies paid towards tuition. After this deadline, no refunds will be issued.

C. For students seeking a refund of tuition: Refunds are based on the amount of tuition paid, fees not included in tuition are non-refundable. Administrative fee of $200 will be deducted from the refund amount. Students who received tuition credit should assume the amount credited will be deducted from the refund amount. All refunds will be made within 45 days of the receipt of the certified letter. Refunds will be calculated as follows: Digital Orientation through Week 2- 75% refund, Week 3 through Week 4- 50% refund, Week 5 through Week 6- 25%, No refunds after Week 6. Students not eligible for refund will be offered the option to take a Leave of Absence (LOA) and return to complete the program within 6 months from withdrawal.

D. Students who have acquired or been offered employment in the field upon enrollment are not eligible for tuition refund. Students who receive a refund will not be eligible to receive any certificates as all courses in the program must be completed to receive a certificate of completion. Students who receive a refund are not eligible for any future institutional scholarships.

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GROUNDS FOR TERMINATION

A student’s enrollment can be terminated at the discretion of the institution for insufficient academic progress, non-payment of academic costs, or failure to comply with rules and policies established by the institution as outlined in the catalog and this agreement.

CATALOG DELIVERY:

Upon execution of this agreement the IMDT catalog, which contains information describing programs offered, will be electronically delivered to you on the date of this agreement. The date executed is .

Initial:

STUDENT ACKNOWLEDGEMENTS:

I have carefully read and received an exact copy of this enrollment agreement. This is a legal binding document and there has been no verbal or written agreements or promises other than those appearing in this agreement.

By checking this you are agreeing to Attestation of a high school graduation or equivalent. You are agreeing to supply the necessary documents if assigned by IMDT.

I understand that IMDT may terminate my enrollment if I fail to comply with attendance, academic, and financial requirements or if I fail to abide by established standards of conduct, as outlined in the school catalog. While enrolled at IMDT, I understand that I must maintain satisfactory academic progress as described in the school catalog and that my financial obligation to the school must be paid in full before a certificate will be awarded.

I understand that IMDT does not guarantee job placement to graduates/students upon program completion or upon graduation.

PARENT/GUARDIAN STATEMENT:

If over the age of 18 years please move forward with the agreement.

Check if you are under the age of 18 and need Parent or Guardian approval for this agreement.

If checked please print the document after completion and have Parent or Guardian Sign below.

____________________________________________

Parent/Guardian Signature

Leave this empty:

Your legal name

Your email address

Timestamp

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