Student Memorandum of Understanding
Local Anesthesia Certification:
Clinical Training Dates: October 11-12, 2013
Hiwassee College ensures all participants in the RDH Local Anesthesia Certification Course understand: 1. Students agree to participate as a recipient of local anesthesia as part of this clinical training. You will give and receive injections throughout the 2 day clinical. As part of the program, students must take and complete the online study prior to clinical. 32 CEUs and a certificate will be awarded upon successful completion. Partial credit cannot be awarded. 2. I will submit the following forms prior to starting the online pre-study: Memorandum of Understanding; medical history form; informed consent form; copy of current, valid dental hygiene license; and copy of current, valid CPR certification. Students who do not provide the required forms by the submitted deadline will not be allowed to participate in the training and will not be issued a refund. The required forms can be downloaded at 3. Forms must be submitted via fax (423) 420-1919 or emailas soon as possible, but no later than August 29, 2013. If Hiwassee College does not receive all required forms by the deadline, Hiwassee College reserves the right to withdraw your seat. You will receive your online study log on information and assignments once you submit all forms. 4. Once forms are submitted, students will be issued a user I.D., password, and the appropriate on-line instructions via your e-mail. The online pre-study is self-paced and takes approximately 40-50 hours to complete. As part of the online study, you need to successfully pass the online quizzes by October 6, 2013. The online pre-study requires that you have access to a computer with a high speed Internet connection and a valid e-mail address. You will not be allowed to participate in any aspect of the clinical training without meeting these criteria. This is a course requirement and a safety issue. 5. Required textbook: Textbooks can be purchased on your own or through the publisher at 6. When a student drops from this course, processing and instructional costs must still be met by the college. Therefore, refunds are issued according to the following schedule. Transfers are not accepted. Withdrawal prior to August 8, 2013 – 100% refund
Withdrawal between August 9-September 1, 2013 – 50% refund
Withdrawal September 2, 2013 or after – No refund
In order to run this course a minimum number of enrollments must be met (to be determined by Hiwassee College). If the course is cancelled by Hiwassee College, students will be issued a 100% refund. Please sign and submit all forms via fax or e-mail to: Leslie Barkley Hiwassee College 225 Hiwassee College Drive Madisonville, TN 37354 Fax: (423) 420-1920 E-mail Questions: please call (423) 420-1234 or (423) 442-2001 ext: 1849 or 1845. Student Memo of Understanding for DHCE-110, Local Anesthesia Course for Registered Dental Hygienists, Fall 2013 Agreement: I have read and understand the above information.
Name (Please print): _____________________________________________________ Signature: _______________________________________ Date: _________________ E-mail Address: _________________________________________________________ Cell phone number: ____________________________________________

Source: http://hiwassee.edu/wp-content/uploads/2013/07/student_memorandum_of_understanding.pdf

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