MODESTO JUNIOR COLLEGE
NURSE ASSISTANT
PROGRAM APPLICATION
AKNOWLEDGEMENT
Student Acceptance of Course Responsibilities
• I have read the attendance policy and understand that I may only miss one theory day and/or one clinical
day and must make up these absences. I understand I must complete 50 hours of theory and 100 hours of
clinical.
• I understand that I must receive a “C” grade or better in theory in order to successfully pass the course and
be eligible for the state competency exam.
• I understand that if I receive a failure in clinical it will result in a grade of “F” for the course.
• I understand that I may not photocopy or print documents containing resident chart information at the
clinical site. I understand that I must safeguard resident privacy per HIPAA guidelines. Failure to adhere to
these guidelines may result in clinical failure and expulsion from the nurse assistant training program.
• I understand that I must adhere to the dress code as described in the student handbook, and that failure to
adhere to the dress code will /may result in expulsion from the nurse assistant training program.
• I understand that I must carry out professionalism in the theory classroom/clinical setting.
• I understand that cheating, dishonesty, unsafe clinical behavior, or any behavior deemed unethical or
inappropriate towards my instructor / classmates or as described in the student handbook may result in
failure and expulsion from the nurse assistant training program.
• I agree to treat all residents and my classmates and instructor with dignity and respect.
• I understand that any prior convictions are reviewed on a case-by-case basis and that I may not be eligible
to work as a certified nursing assistant even upon successful completion of the course.
Rev. 5-27-2020 JM
Last Name
First Name
Signature
Semester:
Year:
Date:
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