Student Handbook Signature
Please complete this form
after reading the
Nursing Assistant Student Handbook
Note, This form will be completed twice, once prior to admission into the program and again before the first day of clinical.
Student ID Number
I have read and I understand the Nursing Assistant Program Handbook. By signing this form, I agree to uphold the policies of the program. I understand that I may be dismissed from the program if I am in violation of any of the policies.
I have read and I understand the Functional Abilities specific to the Nursing Assistant Program provided in this handbook.
I understand that I must disclose all violations to laws including violations at the municipal/local level.
I understand that when signing the Background Disclosure form, local/ordinance violations should be disclosed in addition to all felonies and misdemeanors. Parking tickets or a single speeding ticket do not need to be disclosed.
Do you have a known allergy to latex and/or iodine?
No, I do not have a known allergy to latex and/or iodine.
Yes, I do have a known allergy to latex and/or iodine and have or will send documentation from a health care provider as described in this handbook.
By signing below, I agree all information and answers provided in this form are true and correct.
Signature: (Full name required)