Cover Letter & Checklist

							                                                    Health Occupation Department
                                                Registered Nursing (LVN-RN) Program
                                                  3000 Mission College Blvd., N2-101
                                                         Santa Clara, CA 95054



                              PROGRAM WAIVER/RELEASE OF LIABILITY

Students in the Registered Nursing (LVN-RN) Program are required to learn and practice nursing skills and
procedures prior to performing them on patients in the clinical setting. The undersigned agrees that he/she
understands that students may practice these skills on each other and this may be accompanied by potential
dangers as identified below:

       I understand and acknowledge that as part of the Registered Nursing (LVN-RN) Program, I will be
        required to learn skills required for nursing.

       I understand that these skills may include but are not limited to finger sticks, injections, and
        venipuncture.

       I understand that nursing students may practice these invasive procedures on each other.

       I understand that prior to the skill practice students will receive instruction regarding the skills to be
        practiced including the potential dangers inherent in such procedures.

Therefore, I agree to assume the responsibility and liability for any and all potential risks which may be
associated with participation in such activities. I understand, acknowledge and agree that the West Valley –
Mission Community College District, its instructors, students or volunteers shall not be liable for injury/illness
suffered by me which is incidental to, or associated with preparing for and participating in these learning
activities.


_________________________________________ ________________________
STUDENT SIGNATURE                               DATE

_________________________________________
PRINT NAME

_________________________________________
WITNESS


 This form is to be signed and returned to the Registered Nursing (LVN-RN) Program office no later the
               than the end of the first week of Role Transition Course LVNRN 021 course.




Registered Nursing (LVN-RN) Program
3000 Mission College Blvd.
Santa Clara, CA 95054
(408) 855-5016
Rev. 5/10                                                                                                      1