I, the undersigned, formally apply to participate in the Doctor of Chiropractic Preceptorship Program with Cleveland University-Kansas City. I have read, understand, and agree to comply with the program’s established guidelines and fulfill all responsibilities. By signing below, I certify that I do not currently have any unresolved licensing board disciplinary actions against my license. If during the course of hosting a preceptor, a licensing board action arises, I will immediately notify Cleveland University Kansas City. I further agree to hold harmless Cleveland University-Kansas City, the Board of Trustees, Administration, Faculty and Employees, and the student assigned to me, in any dispute or action arising from diagnostic or treatment procedures occurring in my office.