STEP 1
Verify your email
Students will verify their email with a six-digit code before completing paperwork. This protects returning students' records without requiring an account.
STEP 2
Waiver and Release of Liability
WTFD Form 18 — Rev. 6/10. Department wording preserved for legal review; witness fields excluded from the proposed electronic version.
WAIVER AND RELEASE OF LIABILITY
In consideration of being granted permission by the Chief of the Washington Township Fire Department to accompany members of the Washington Township Fire Department in the performance of their duties; to ride in and occupy Washington Township fire and emergency service vehicles; to receive training from members of the Washington Township Fire Department and to be granted access to non-public portions of Washington Township facilities, the undersigned hereby agrees to the following:
1. I, on behalf of myself, my heirs and my estate, do hereby affirmatively and unconditionally release Washington Township, its elected officials, employees and agents from any and all claims of any type and nature including, but not limited to, any claims for personal injury or property damage.
2. I acknowledge that accompanying members of the Washington Township Fire Department in the performance of their duties; riding or occupying Washington Township fire and emergency service vehicles; receiving training from members of the Washington Township Fire Department or from being granted access to Washington Township facilities is inherently dangerous and that said risk of danger cannot be eliminated. Nevertheless, I hereby voluntarily accept said risk and agree to hold Washington Township, its elected officials, employees and agents harmless from any injuries or damages which I may sustain while accompanying members of the Washington Township Fire Department in the performance of their duties; riding or occupying Washington Township fire and emergency service vehicles; receiving training from members of the Washington Township Fire Department or from being granted access to Washington Township facilities.
3. I agree to hold harmless and indemnify the Board of Trustees of Washington Township, its elected officials, employees, agents and volunteers from any claims of any type and nature which may arise from accompanying members of the Washington Township Fire Department in the performance of their duties; riding or occupying Washington Township fire and emergency service vehicles; receiving training from members of the Washington Township Fire Department or from being granted access to Washington Township facilities.
4. I agree to comply with the Health Insurance Portability Act of 1996 (HIPPA) which includes, but is not limited to, the nondisclosure of any individually identifiable health information ("personal health information") obtained, viewed, accessed or overheard by me while accompanying members of the Washington Township Fire Department in the performance of their duties; riding or occupying Washington Township fire and emergency service vehicles; receiving training from members of the Washington Township Fire Department; being granted access to Washington Township facilities or being granted access to or using the Washington Township computer system.
STEP 3
Student / Guest / Trainee Confidentiality and Non-Disclosure Agreement
Proposed electronic version for students; original department text submitted for review.
STUDENT / GUEST / TRAINEE CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT
I understand that Washington Township Fire Department provides services to patients that are private and confidential and that I am a crucial step in respecting the privacy rights of Washington Township Fire Department's patients. I understand that it is necessary, in the rendering of Washington Township Fire Department services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written or photographic and that all such information is strictly confidential and protected from improper use and disclosure by federal and state laws.
I agree that I will comply with all confidentiality and security policies and procedures set in place by Washington Township Fire Department during my experience as a student/guest/trainee with Washington Township Fire Department. If at any time I knowingly or inadvertently breach the patient confidentiality or security policies and procedures, I agree to notify the Privacy Officer of Washington Township Fire Department immediately.
I also understand that I may be exposed to other confidential or proprietary information of Washington Township Fire Department and I agree not to reveal any of that information to anyone at any time.
In addition, I understand that a breach of patient confidentiality may result in immediate suspension or termination of the privilege to gain clinical experience or observe the activities of Washington Township Fire Department. Upon termination of this privilege for any reason, or at any time upon request, I agree to return any and all patient confidential information in my possession. As a general rule, I understand that any patient or confidential information that I see or hear while as a student/guest/trainee will stay here at Washington Township Fire Department when I leave.
I have been given an overview of the privacy policies and procedures and have been given access to review those policies. I agree to abide by all policies or my privilege to participate in clinical activities or to otherwise observe Washington Township Fire Department activities will be terminated.
Participant type: Student
STEP 4
Electronic signatures
The final process will record a separate electronic signature and timestamp for each document. Each will expire one year from signing, subject to department-approved terms.
Signing is disabled until the secure storage workflow has been tested.
Signatures will be recorded only after both documents are acknowledged and the verified session is active.