AMERICAN RED CROSS DENTAL ASSISTANCE COURSE AGREEMENT 1. The Dental Clinic and the American Red Cross reserve the right to request that each person participating in this program submit to examinations that are necessary to determine the student’s physical and mental conditions, health and/or suitability for the program and for work in a medical treatment environment. 2. Students in this program must meet all Dental Clinic standards, including those pertaining to dress, conduct, physical appearance, hygiene, health, safety, and infection control. Including but not limited to the following: a. Students must be neat in appearance. Hair must be worn in a manner so that it does not extend below the collar of the uniform while volunteering in the Dental Clinic. b. While volunteering in the clinic students must wear scrubs (which will be provided) and footwear other than their street shoes. 3. Students are considered Red Cross volunteers and must wear their Red Cross nametag at all times while in the Dental Clinic. Students are also responsible for submitting their hours to the clinic’s supervisors to be approved and then entered into Volunteer Connections (ARC online system). 4. Students must maintain current Red Cross CPR certification while working in the Dental Clinic. 5. More than three unexcused absences is grounds for removal from the program. Students must pre-arrange a schedule for volunteering in the clinic with the Dental Program coordinator and are expected to follow this as closely as possible. 6. Extended time off must be prearranged and approved by Red Cross and Dental Program coordinators. 7. Students are expected to conduct themselves in a professional manner and maintain acceptable personal relationships with co-workers and supervisors, which includes no fraternization. Any personnel issues or concerns should be immediately brought to the attention of the Red Cross and Dental Program Coordinator. 8. Applicants must receive all of the hospital’s required immunizations, along with the three shots in the hepatitis vaccination and have a positive titer prior to volunteering in the clinic 9. The Dental Clinic and the American Red Cross may terminate this agreement with a student at any time without cause or advance notice and require the student to immediately leave the training program. In addition, students may be dismissed for failure to comply with any requirement imposed by this agreement.

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I have read this agreement, understand, and agree to comply with it and the rules and policies governing this program, including those which may be hereafter imposed. I understand that failure to comply with American Red Cross and Dental Clinic regulations may lead to dismissal from the Dental Assistant Program.

________________________________________________________________________ Signature, Student Date

________________________________________________________________________ Signature, Dental Clinic Coordinator Date

________________________________________________________________________ Signature, Red Cross Program Coordinator Date

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