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Affiliation Agreement # 11205 Page 7 of 7 <br />APPENDIX A <br /> <br />STUDENT RESPONSIBILITY STATEMENT <br /> <br />This acknowledgment is made by the student identified below to acknowledge certain duties and responsibilities with regard <br />to participation in an educational experience in the Arizona Board of Regents for and on behalf of Northern Arizona University <br />(“University”) program at the location where the educational experience takes place (“Facility”). <br /> <br />DUTIES AND RESPONSIBILITIES OF STUDENT <br /> <br />1. The student will complete and be responsible for the cost of providing all health forms , health insurance, testing, <br />and certificates requested by the Facility. <br /> <br />2. The student will comply with all applicable policies, procedures, and rules of the Facility. <br /> <br />3. The student will participate in orientation, required mandatory education, and skill training as required by the <br />Facility. <br /> <br />4. The student will demonstrate professional behavior appropriate to the environment, including adhering to the <br />Facility’s established dress code and maintaining high standards at all times. <br /> <br />5. The student will follow the policies, rules, and regulations of the Facility, including those regarding confidentiality of <br />information. <br /> <br />6. The student’s conduct at all times, both at the Facility and outside normal business hours, will be in a personally and <br />professionally ethical manner. <br /> <br />7. The student will make appropriate arrangements for transportation and housing, if necessary, and be responsible <br />for all travel and living expenses incurred in relation to the educational experience. <br /> <br />8. The student agrees that University may share information received from a student's Criminal Background Check <br />and Drug Testing with the Facility, if applicable. <br /> <br />9. The student will conform to the work schedule of the Facility and make up time and work missed during <br />unavoidable illnesses, in consultation with Facility supervisor, the student’s University placement coordinator <br />and/or instructor. <br /> <br />10. The student will obtain prior written approval from University and the Facility before publishing or presenting any <br />material relating to the educational experience outside the normal educational settings of the University. <br /> <br />11. The student acknowledges the inherent risk of exposure to COVID-19 which exists in any public place where people <br />are present. COVID-19 is an extremely contagious disease that can lead to severe illness and death. By <br />participating in the program, the student assumes all risks related to exposure to COVID -19. <br /> <br />I HAVE READ AND UNDERSTAND THIS ACKNOWLEDGMENT AND AGREE TO ABIDE BY ITS TERMS AND CONDITIONS: <br /> <br />Student Name: <br /> (Please type or print) <br /> <br /> <br />Student Signature Date <br />