MODESTO JUNIOR COLLEGE
ALLIED HEALTH and FAMILY & CONSUMER SCIENCES DIVISION
NURSE ASSISTANT TRAINING PROGRAM
STUDENT HANDBOOK
RELEASE OF LIABILITY FORM
I, ___________________________________________________, understand that participation in
the clinical component of the MJC Nurse Assistant Training Program may be physically and
emotionally demanding. My signature below states that with reasonable accommodations I am
physically and mentally able to meet the expectations imposed by the typical nurse assistant activities
listed below.
Activities and physical abilities that are required of students in the clinical/long term care facility
include, but are not limited to:
• Lifting 50-75 pounds
• Transferring 100 pounds
• Bending, stooping, kneeling
• Pushing, pulling
• Walking
• Standing for prolonged periods (may include 10-hour shifts)
• Reaching
• Hearing acuity (average)
• Visual acuity (average)
• Manual dexterity
• Tactile ability – sufficient for patient care
• Equipment operations – transfer devices, scales, etc.
For those clinical experiences that are deemed essential by the clinical provider, I understand that
alternate clinical experiences may not be available. I also understand that timeliness of performance
may be, in some instances, an essential component of the clinical experience and, in those instances,
it may not be possible to grant an extension of time as an accommodation. This will be determined
on an individual basis.
To request reasonable accommodations or to discuss whether reasonable accommodations are
appropriate, please contact the Allied Health office (575-6362) and request an appointment with the
Nurse Assistant Program Director.
Regardless of whether or not I am an individual with a disability, I will report to my instructor if I
develop or experience any physical, psychological, or emotional problems that might impair my ability
to perform nurse assistant duties after I sign this release.
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Rev. 5-27-2020
_____________________
_____________________
Semester:
_______________
Year:
Last Name
First Name
Signature
Date:
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