Enrollment Packet form

Drug Testing Consent

Pursuant to the Lakeview College of Nursing Drug Policy, Student Handbook, you must submit this form to enroll in classes at Lakeview College of Nursing. If you have questions regarding this form, this policy, or other policies in the Student Handbook, you should discuss them with a faculty member or your academic advisor.

By submitting form, I swear and affirm that I have read and understood the Lakeview College of Nursing Drug Policy, that I have had ample opportunity to discuss said policy with Lakeview College of Nursing faculty, my academic advisor, and/or an attorney of my choosing.

By submitting this form, I agree to abide by the Lakeview College of Nursing Drug Policy. I consent to being drug tested in accordance with the Lakeview College of Nursing Drug Policy. I authorize each and every provider of medical services, including but not limited to drug test providers, to cooperate fully with Lakeview College of Nursing personnel, and to release any and all requested medical records and information deemed necessary for enforcement of the Drug Policy. I acknowledge and agree that:

I am subject to drug testing without prior notice or warning.

I must appear for said testing at the time and location determined by Lakeview College of Nursing, or be sanctioned for a positive drug test.

I may be subjected to any method of screening of my blood, breath, or urine for controlled, illegal, or prohibited substances, including but not limited to urinalysis, blood draw, and breathalyzer tests, in the sole discretion of Lakeview College of Nursing.

Lakeview College of Nursing personnel and clinical partners may access and review the results of my screenings for any purposes related to enforcement of the Lakeview College of Nursing Drug Policy and policies of clinical partners.

I am responsible for appearing at the date and time which I am notified to appear for testing, even if I am impaired at the time I received said notice.

If I test positive for the presence of a controlled, illegal, or prohibited substance on a drug test, or otherwise violate the Lakeview College of Nursing drug policy in any way, that I will be subjected to sanctions as set forth in the Lakeview College of Nursing Drug Policy and the Student Handbook, up to and including dismissal from Lakeview College of Nursing.

I specifically acknowledge and understand that missing a scheduled drug test, or tampering with the test in any way, shall be considered a violation of the Lakeview College of Nursing Drug Policy.

Acknowledgement and verification of information

Release of Health Information/SSN - I give my permission to LCN to request/release my health information and Social Security Number (when required), to health care agencies who require such information for me to attend clinical experiences in their facility.

Student Handbook (http://www.lcn.edu/cataloghandbook) - I acknowledge that I am responsible and accountable for all policies, procedures and information contained within the College's website.

Review of Student File Information (Accrediting Bodies) - I understand that the visitors from accrediting organizations may view my student file and LCN records. I am aware that this consent is valid for the entire time I am a student at LCN.

Permission to Copy/Retain Class Assignment - Faculty of LCN have my permission to copy and/or retain any assigned work, legacy projects, and/or papers that I complete in my nursing courses to use as teaching tools for future semesters. I understand that this work may be shared with affiliated agencies and/or accrediting bodies of LCN.

Assumption of Risk Agreement and Release of Liability - I hereby assume all responsibility for any and all risk of damage or injury that may occur during participation in a field trip, and discharge/release LCN and all affiliations from all claims, demands or causes of action.

Photo/Video Release - I agree to appear in ads/brochures/videos/displays/or web site materials. LCN may use photos/video/etc. for broadcasting, marketing and advertising purposes in any manner, at any time, and at any place they choose. LCN may use my name, voice and likeness, together with any biographical or other information concerning me in connection with the ad/brochure/video/display/web site materials for marketing, advertising, or any other purpose.

Standards of Behavior - I understand that it is a great honor and privilege to study and work in the nursing profession. I promise to uphold the highest standards of ethical and compassionate behavior while learning, caring for others, and/or participating in educational activities. I will strive to uphold the spirit and letter of this code during my time at Lakeview College of Nursing.

Campus Security - I have read and understand the Campus Security report.

Drug Policy - I have read and agree to abide by the Lakeview College of Nursing Drug Policy. I consent to being drug tested in accordance with the Lakeview College of Nursing Drug Policy. I authorize each and every provider of medical services, including but not limited to drug test providers, to cooperate fully with Lakeview College of Nursing personnel, and to release any and all requested medical records and information deemed necessary for enforcement of the Drug Policy.

Sexual Harassment - I have read and understand the Lakeview College of Nursing sexual harassment document.

News Releases, Web Sites & Social Sharing - I agree to have my accomplishments recognized by Lakeview College of Nursing through news releases as well as Lakeview's social media site and website. I understand that Lakeview uses software that distributes these achievements to hometown newspapers and that there will be an online profile created for me. Additionally, I understand that student achievements are also often posted on Lakeview's website(s) and social media page(s). Please provide the requested information so that we can properly recognize your accomplishments. You may opt-out later if desired.

Permission to conduct business electronically - I give my permission to conduct business with Lakeview College of Nursing using electronic methods, including, but not limited to, registration, admissions, financial aid, and student accounts. This consent also includes receiving my 1098-T statement electronically within the student portal (SONIS), where it will be available annually by January 31st.

Required Clinical and Hometown Information

During a student's time at Lakeview, the student will attend clinical facilities that will require information to be able to have access to the computer system during clinical hours. Providing this information ensures that the student's log-in is ready when starting clinicals. Additionally, this information will be used for sharing your accomplishments with others as described above.

Student's first name:

Student's middle name:

Student's last name:

Mother's maiden name:

Student's eye color:

Student's natural hair color:

Student's height:

E-mail address:

Gender:

Male

Female

Hometown

City:

State:

ZIP code:

High school education

Name of school:

City:

State:

Graduation year:

College education

Name of school:

City:

State:

Graduation year:

Parent 1

Last name:

First name:

Middle name:

E-mail address:

City:

State:

ZIP code:

Parent 2

Last name:

First name:

Middle name:

E-mail address:

City:

State:

ZIP code:

Parents should be listed:

together

separately

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Enrollment Packet form

Drug Testing Consent

Acknowledgement and verification of information

Required Clinical and Hometown Information

Hometown

High school education

College education

Parent 1

Parent 2

By submitting this form, I agree to all of the above.