Clinical Internship Student Registration

page 6 of 6

STUDENT ATTESTATION

By checking the box for each document I, hereby certify that the following documents are on file at the contracted college office. The school will be responsible for submitting any requested document for Kindred, inspectors and surveyors upon request. For questions please contact the Student Programs Department at scheduleyourclinical@kindred.com.

Student Documentation

Medical Information Documentation

*If you are unsure if you meet all the above requirements please connect with your faculty coordinator to verify, prior to submitting your registration.

Students' Communicable Disease Certification

The student does hereby certify that he/she is enrolled in and does not presently have a communicable disease or communicable health problem that might or could jeopardize patient or employee health at . hereby agrees to notify Kindred if he/she contracts or becomes aware that he or she has a communicable disease or communicable health problem that might or could jeopardize patient or employee health care at .

Dated this the 4 day of December, 2020.