Activekidz & Adult Therapy ~ Student Observation Request
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Hello!  Please fill out this form to better help us accommodate your need.  We will reach out to you as soon as possible!
I am interested in
Are you willing to travel to more than one location for your hours?  Please select all options.
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Is this for class credit?
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Month(s) You Want to Shadow
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Student Name: 
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Address:
Phone Number
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Emergency contact name and phone number
I am a student at
I am a
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Do you agree that you will uphold the highest standards of behavior when participating in educational activities/observations at Activekidz & Adult Therapy. 
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Do you understand that any information that is discussed while participating in or observing therapy at Activekidz & Adult Therapy is to remain confidential and should not, under any circumstances be discussed outside of Activekidz & Adult Therapy.
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Do you agree to remain with the appropriate therapist in the treatment rooms at all times and not to engage in manipulation of any piece of equipment without explicit permission from a staff member or therapist of Activekidz & Adult Therapy?
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Activekidz & Adult Therapy encourages the interest in, and the pursuit of, occupations in health care services that benefit children and their families. This organization strives to provide innovative, top-quality therapeutic services to our clients and in the pursuit of our mission and vision we also take responsibility for stimulating the interest and education of future Occupational, Speech, and Physical Therapists in the community. Do you understand that should your behavior be inconsistent with the mission of this agency, you will be asked to discontinue your affiliation immediately?
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In consideration for the privilege to participate as a student observer you hereby agree to hold harmless and indemnify Activekidz & Adult Therapy, its affiliates and subsidiaries, owners, and principals, and employees and contracts and further release them from any liability or responsibility for accident damage, injury, illness, or death to you or the property owned by you. Furthermore you understand and agree that you will be both civilly and criminally responsible for failure to maintain compliance with the policies set by Activekidz & Adult Therapy as well as those requirements set by law.

Do you agree with these policies and procedures and promise to abide by them during and after your affiliation with this agency?
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