Student-Instructor Attestation Form

School hereby attests that it has in its possession and will maintain at the Location listed below current, up-to-date documentation demonstrating that the students and/or instructors listed on the document attacehd hereto are in compliance with the testing, vaccine, background check, liability insurance and other requirements set forth in the Affiliation Agreement betwenn Pikeville Medical Center, Inc. (PMC) and School. School further attests that each listed student and instructor is currently certified in CPR. School will provide documentationof the foregoing to PMC promptly upon PMC's request.

Location where documentation is kept:

Location Contact Information:

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

in current, the

Title

Date / Time

Date

Time