Learner and Volunteer Contract (Required by All Applicants at Guardian Primary Care)

REQUIRED

Instructions

• This contract is required by all Learners and Volunteers before their start date.
• Please review and complete the contract and provide all the requested documents listed in the contract.
• Send completed form with supporting documents to GPC Director (contact info listed at the end of the contract)
• Questions should be directed to the GPC Director.
• Please allow 5 business days for Review

Student/Observer/Resident/Shadowing/Volunteer Agreement

Requested Start Date:

Requested Start End

Under the supervision of Guardian Providers or their designees, this Agreement ("Agreement") is entered into between Guardian Primary Care ("GPC") and ("Applicant") for the purpose of permitting the Applicant to observe and/or participate in clinical activities for educational and/or volunteer purposes.

1. Purpose

The purpose of this contract is to establish the foundation and ground rules for which the Applicant will be allowed to observe and/or participate in clinical operations, patient interactions, and healthcare delivery for educational and/or volunteer purposes only. This is not an employment relationship, and no compensation or benefits will be provided.

2. Scope of Participation

• The Applicant must specify whether they are requesting Observer Status (no patient contact), Hands-On Learning Status (direct patient care under supervision) or Volunteer Status (direct patient contact must be approved by GPC leadership).
• Observers and volunteers not approved for patient contact may not physically touch patients or participate in any direct patient care.
• Hands-On Applicants may not touch, examine, or perform procedures on a patient unless their assigned preceptor is physically present and actively supervising and has authorized the interaction.
• No Applicant (observer or hands-on) may initiate or maintain patient contact outside of the clinic setting regarding any aspect of their healthcare.
• Guardian Primary Care reserves the right to approve or deny access to electronic health records (EHR) or charting systems upon request.

• GPC patients and/or legal guardians may refuse the participation of students and volunteers with or without explanation at any point in time prior to the student engagement in any aspect of patient care as defined by Missouri and federal law.

• If a clinic patient or legal guardian refuses student or volunteer participation at any point, for any reason, whether disclosed or undisclosed, the student or volunteer shall cease participation in the patient’s care immediately.

3. Compliance with Laws, Policies, and Regulations

• The Applicant is responsible for following all applicable local, state, and federal laws (including HIPAA) regarding patient care and ethical conduct.
• The Applicant must adhere to all policies and procedures of their educational institution and Guardian Primary Care.
• The Applicant must maintain their own professional liability (malpractice) insurance and provide proof of current coverage upon request.
• Guardian Primary Care is not responsible for any acts, omissions, or errors made by the Applicant.
• The Applicant agrees to background checks at any time at the discretion of GPC leadership. Registries that may be checked include, but are not limited to:

• Criminal Search - County
• Criminal Search - Federal
• Criminal Search - State Wide
• FACIS - Level 1 Individual
• ID Trace Pro
• National Criminal Database
• National Sex Offender Public Registry

4. Confidentiality and Proprietary Information

• Applicants must maintain strict confidentiality regarding all patient health information (PHI) and proprietary business information.
• Applicants may not store, keep, duplicate, photograph, record, business operation details or resources, or otherwise retain any patient information or clinic documents outside of authorized systems.
• Any breach of confidentiality will result in immediate dismissal and may carry civil and/or criminal penalties.

5. Conduct, Appearance, and Professionalism

The Applicant shall:

• Behave with professionalism, integrity, and respect toward all patients, staff, and providers.
• Adhere to a dress code of business casual attire (with or without a lab coat) or clean, professional scrubs. Clothing must be neat, clean, and well-kept. Additionally, all dress code policies of the practice almanac shall be upheld at all times.
• Wear visible identification at all times while at Guardian Primary Care.
• Comply with all instructions given by supervising providers or staff.
• Immediately notify their preceptor if they feel that learning is not being prioritized over service tasks.

6. GPC Responsibilities

• The Applicant is responsible for documenting their own clinical hours, experiences, evaluations, and requesting any necessary signatures or documentation from their preceptor.
• The Applicant acknowledges that education and skill development are the primary objectives, not clinical labor.
• If concerns arise, the Applicant agrees to first communicate directly with their assigned preceptor and escalate to their educational institution only if unresolved.
• The Applicant must obtain and document explicit verbal permission from the patient and/or the patient's guardian to partake in any patient encounter.
• If any safety or health concerns with the patient, preceptor, or Applicant occur at any point in time, it is the responsibility of the applicant to report this to the appropriate supervisors, instructors, and/or authorities as applicable.

7. Infection Control

• Applicants must comply with all infection prevention and control protocols.
• Applicants experiencing symptoms of contagious illnesses must notify their preceptor and refrain from attending clinical activities.
• Applicants may be required to provide proof of vaccination per CDC guidelines for healthcare personnel, submit background checks, or undergo drug screening upon request.

8. Non-Discrimination

• Guardian Primary Care provides equal opportunities for all Applicants without discrimination based on race, color, religion, sex, gender identity, sexual orientation, national origin, disability, or age.

9. Photo, Video, and Recording Policy

• Photography, videography, audio recording, or similar activities are prohibited without express, written permission from Guardian Primary Care and the patient involved.
• With the written, expressed consent of the Applicant, Guardian Primary Care may post, distribute, and store assets depicting and/or referencing the Applicant for marketing, business, and creative purposes. Assets are defined as images, videos, media content, written articles, descriptions, and captions illustrating and/or detailing the student’s experience.
• Guardian Primary Care agrees to adhere to all marketing policies and guidelines of any affiliate or governing body and/or institution of which the Applicant may be a student and/or affiliate. Any use of logos, brand, or referencing in any context of any institution of which the Applicant is a student, member, or affiliate may only be posted and distributed with the written, expressed consent of the organization or institution's policies. Guardian Primary Care understands that in most cases, the Applicant does not possess the authority to provide this consent.

*By signing below, I acknowledge I am 18 years of age or older and am the person named below and/or legal guardian authorized to sign on behalf of the Applicant

By signing below, I DO authorize Guardian Primary Care to post, distribute, and store assets depicting and/or referencing the Applicant.

Applicant Name (First and Last): 

Applicant Signature: 

Date:

Legal Guardian Name (First and Last): 

Legal Guardian Relationship to Patient:

Legal Guardian Signature: 

Date:

By signing below, I DO NOT authorize Guardian Primary Care to post, distribute, and store assets depicting and/or referencing the Applicant.

Applicant Name (First and Last): 

Applicant Signature: 

Date:

Legal Guardian Name (First and Last): 

Legal Guardian Relationship to Patient:

Legal Guardian Signature: 

Date:

10. Liability Waiver

• The Applicant assumes full responsibility for any and all risks associated with participation.
• Guardian Primary Care shall not be liable for any injuries, illnesses, legal actions, or damages resulting from the Applicant’s participation or actions.

11. Termination

• Guardian Primary Care reserves the right to terminate this agreement at any time, with or without cause, without prior notice.
• The Applicant may terminate their participation at any time by notifying their preceptor.

12. Compliance Checklist

The following items are required before starting clinical activities:

• Proof of active malpractice insurance submitted. (PLEASE ATTACH A COPY TO THE CONTRACT-REQUIRED BY ALL APPLICANTS PARTAKING IN DIRECT PATIENT CARE and CONTACT)
• Government Issued Real Photo ID (e.g., Driver’s License)
  
• Proof of vaccination record (or waivers) submitted or obtained per CDC guidelines.
  
• Background check submitted (if requested).
  
• Drug test completed (if requested).
  
• Confirmation of observer vs. hands-on learning status submitted.
  
• Proof of compliance with educational institution policies.
• Proof of enrollment in an accredited educational institution if applying as an affiliate of an educational institution (e.g., transcripts, acceptance letter, etc - must be an official document from the institution) - If applicable
  
• Review of Guardian Primary Care policies and procedures.
  
• Review of applicable state and federal laws regarding patient privacy and ethics.

13. Clinical Site affiliations

Is this clinic learning and/or volunteer experience in coordination with (check which applies):

• An educational university, college, earning program, or external institution
• Individual endeavor, no institutional affiliation

If your learning and/or volunteer experience is occurring in affiliation with an external institution, please provide:

Name of Institution:

Address of Institution (Street Address, City, State, Zip):

Program Director/Coordinator Name and Credentials:

Program Director/Coordinator Email:

Program Director/Coordinator Phone Number:

14. Acknowledgment

By signing below, I acknowledge that:

• I have read, understood, and agreed to all terms outlined in this Agreement.
• I understand I will not receive compensation for this educational experience.
• I understand that Guardian Primary Care has sole discretion over chart access and clinical participation.
• I understand that confidentiality, professionalism, and patient safety are paramount.
• I certify that I have met all the requirements in the Compliance Checklist.
• I have received a copy and/or been provided access to the practice almanac and understand all parts of this document. I agree to abide by all policies and rules contained in the practice almanac.
• I understand that Guardian Primary Care is not responsible for my actions.
• I agree to notify my preceptor first regarding concerns about the clinical learning environment, prior to contacting my instructor.

Applicant Name (First and Last): 

Status Requested: 

• Observer Only
• Hands-On Learning

Type of Student (Medical, Nursing, et cetera):

Applicant Signature: 

Date:

Legal Guardian Name (First and Last): 

Legal Guardian Relationship to Patient:

Legal Guardian Signature: 

Date:

GPC Representative (Preston Holifield, DNP, APRN, FNP-C or Designee):

Signature: 

Date:

If you have questions about this form, please contact:

Preston Holifield, DNP, APRN, FNP-C

GPCal Director

E| preston.holifield@guardianprimary.com

P| (573)-200-6143

F| (​​573)-​​755-0706

CHART ACCESS REQUEST FORM

(OPTIONAL-Applicant MUST BE 18 YEARS OR OLDER)

Applicant Full Name (First, Last):

Date of Birth (MM/DD/YYYY):

Email:

Phone Number: 

Home Address:

Role (e.g., Medical Student, Nursing Student, PA Student, etc.):

Requesting Chart Access? 

• Yes
• No

Purpose for Access (briefly explain):

Preceptor Name:

*By signing below, I certify that all the information provided herein is true and current. I agree to only access Guardian’s system for learning purposes. I will not access the chart outside approved clinical times and agree to uphold the highest standard of ethics and standards as I understand I will be a direct reflection of my Guardian Primary Care and my learning institution (if applicable) during my time as a Applicant.

Preceptor Name:

Preceptor Signature (for endorsement): 

GPC Approval (Guardian Primary Care use only):

• Approved
• Denied

GPC Representative Signature: 

Date:

Once completed, please email the form to myprovider@guardianprimary.com, fax it to (573)-755-0706, or bring it in person to the Guardian Primary Care clinic location where you will be learning. If approved, you will receive email instructions on how to access your account and when it will be available to you.

If you have questions about this form, please contact:

Preston Holifield, DNP, APRN, FNP-C

Clinical Director

E| myprovider@guardianprimary.com

P| (573)-200-6143

F| (​​573)-​​755-0706