Participation Acknowledgement. I am participating in the professional field experience with the Entities as part of my educational experience in the Department at Xavier during the Academic Year listed above (the “Experience”). I acknowledge that the last page of this Agreement lists the classes that include professional field experiences. I assert that I am enrolled in one or more of the classes listed for this Department, and I understand that Experiences in those classes will be covered by this Agreement. I understand that these Experiences will be conducted at the various off- campus Locations listed above. I understand that these Experiences may include but are not limited to the following kinds and types of Experiences: assessments, classroom observations, clinical work, internships, interventions, labs, modules, practicums, research, role transitions, and service learning.
Participation Acknowledgement. I hereby authorize the University of Hartford to reduce my cash compensation as indicated above for each pay period during the plan year following the date of this agreement. I understand that this election form cannot be revoked or changed during the plan year unless there is a change in my family status which qualifies for a revocation or change (e.g. marriage, divorce, death of spouse or child, birth or adoption of child, or termination of employment of spouse). I further understand that salary reductions must be reimbursed for qualified expenses incurred during the plan year. If, at the end of the plan year, the total reduction in compensation exceeds my qualified expenses, I understand that the difference in amounts in excess of $500 will default to the plan. I have read and understand the rules regarding the use of my debit card for eligible health care FSA expenses. I certify that the card will only be used for eligible medical expenses at eligible providers. I further certify that the amount of eligible expenses is not reimbursable from any other source, nor will I attempt to be reimbursed from any other source. I will maintain substantiation for all expenses and where required, provide applicable substantiation upon request. If I cannot produce adequate substantiation, I understand that I must repay the plan for such an expense. My signature below indicates that I have read and understand this election form and the descriptive material(s) provided. Participant Signature Date Agreed and accepted by Date University of Hartford Representative HRD USE ONLY [ ] PDADEDN completed by: Date: [ ] PayFlex Notification completed by: Date:
Participation Acknowledgement. I am participating in a clinical rotation (“the Experience”) as part of my program at the University of St. Augustine for Health Sciences (“USAHS”). I understand that clinical, field placement, internship sites and/or USAHS retain the right to cancel student participation at any time to protect the safety of students, staff, and patients.
