Mohave Community College * 1977 Acoma Blvd, West * Lake Havasu City, AZ 86403 * PTA Program Support 928-505-3351
Physical Therapist Assistant Program
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Waiver for Release of Personal Information
Student Information
Student Name:
Student ID#:
Home Phone:
Cell Phone:
Release Statement
Mohave Community College presents courses, labs or workshops as a part of the Physical
Therapist Assistant program in collaboration with diverse public and private health
organizations, including health agencies, hospitals and clinics. Those collaborating
organizations permit the College to conduct such courses within each organization’s facilities,
but require that all participants, whether instructors or students, furnish qualifying health
records and information, including but not limited to, immunizations, titer results, results of
drug screens, the individual’s contagious disease history, background check, and fingerprint
card, and a copy of a valid CPR card. The collaborating organizations established health
requirements may vary.
By signing below, I am stating that I understand the above statement, and hereby authorize
Mohave Community College to release any of my records and information in their possession
to such organizations, for the purpose of qualifying me to participate in such instructional
courses, labs or workshops.
Student Name:
Student Signature:
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