Student Participation, Consent, Assumption of Risk, Release Of Liability Form

IMPORTANT: This form affects your legal rights. Please read it before signing.
 
1. Hands-on practice and consent. I voluntarily agree to take part in hands-on dental hygiene practice. I may perform procedures on classmates, and classmates may perform procedures on me, under instructor supervision. Procedures may include, as applicable, oral examination, instrumentation and scaling, ultrasonic instrumentation, polishing and radiographs. This is training, not complete dental care. Professional Learning Services LLC (“PLS”) will not provide a full dental examination, diagnosis, treatment plan, or follow-up care. I will obtain needed care from my own dentist or physician.
2. Health and safety. Before practice, I will tell an instructor about any health or dental condition, allergy, medication, pregnancy, recent procedure, or other concern that may affect safe participation. I will follow all safety and infection-control directions. I may ask questions or stop a procedure at any time. I understand that stopping may affect my ability to complete the course.
3. Risks and assumption of risk. I understand that instructor supervision does not remove all risk. Practice can cause discomfort, pain, bleeding, cuts, bruising, swelling, soreness, infection, allergic reaction, damage to teeth or restorations, and temporary or lasting nerve or soft-tissue injury. I voluntarily accept these risks and other risks that are not listed or cannot be predicted.
4. Blood or body-fluid exposure and medical costs — Student initials: ______. I understand that sharp instruments and contact with blood or body fluids can expose a person to HIV, hepatitis B, hepatitis C, or other bloodborne infections. If I am cut, punctured, or exposed—or if my blood or body fluid exposes another person—I will stop, report the incident immediately, follow first-aid directions, and cooperate with PLS’s exposure-response procedure. The exposed student must obtain prompt medical evaluation. The student whose blood or body fluid was the source of the exposure must promptly obtain medically recommended testing, subject to rights provided by law. Each student is responsible for all costs related to that student’s initial evaluation, laboratory testing, medications, treatment, and follow-up care. PLS does not provide or pay these costs.
5. Release of liability. To the fullest extent allowed by Florida law, I release and agree not to sue PLS, its owners, officers, employees, independent contractors, instructors, clinical supervisors, agents, host facilities, and participating students (together, the “Released Parties”) for any injury, loss, claim, or damage arising from the course or hands-on practice, including a claim caused by the ordinary negligence of a Released Party. This release does not apply to conduct that the law does not allow to be released.
6. My responsibility and emergency care. I am responsible for claims or losses caused by my intentional conduct or my knowing failure to follow safety instructions. I authorize PLS to contact emergency services if reasonably necessary. I understand that PLS is not responsible for arranging or paying for medical care.
7. Training records. Practice information is used only for training and is not kept as a clinical record. PLS may keep this signed form and any incident report.
8. IMAGE, VIDEO, AND VOICE AUTHORIZATION — INITIAL ONE:
 _____ YES I authorize PLS and those acting for it to photograph or record my image, voice, and participation and to use the material, without payment, for education, training, websites, social media, advertising, promotion, and legal purposes. PLS may edit or crop the material. PLS will not use my full name without separate permission.
 _____ NO I do not authorize PLS to use identifiable images, recordings, or my voice for these purposes.
9. Acknowledgment. I am at least 18 years old. I have read and understand this form. I had the opportunity to ask questions. I sign voluntarily. Florida law applies. If any part is not enforceable, the rest remains effective. I intend this agreement to bind my estate and personal representatives.
 
____________________________         __________              ____________________________                       ___________
Student signature                                        Date                    PLS representative / witness                             Date