SCHOOL OF NURSING BETTY WHITE HEALTH CENTER

BY SIGNING THE DOCUMENT, I INDICATE THAT I HAVE READ, I UNDERSTAND, AND I AGREE TO THE SCHOOL OF NURSING DRUG TESTING POLICY. I UNDERSTAND THAT A NEGATIVE DRUG TEST IS REQUIRED FOR ADMISSION AND FOR PROGRESSION IN THE SCHOOL OF NURSING. THIS NOTARIZED DOCUMENT CONSTITUTES MY CONSENT FOR DRUG TESTING BY A SCHOOL OF NURSING DESIGNATED LABORATORY. IT ALSO CONSTITUTES CONSENT FOR THE LABORATORY TO RELEASE THE RESULT OF MY DRUG TEST TO THE CHAIR OF THE SCHOOL OF NURSING OF NURSING.

In Witness, Whereof, this instrument is executed this the day of_____, 20___. WITNESSES:

Witness #1 Signature Student's Signature

Witness #2 Signature Student's Printed Name

STATE OF ___

COUNTY OF___

On this day of_____,20___, before me appeared

to be known to be the person described in and who executed the

foregoing instrument, and acknowledged that

___execute the same as free act and deed. Given under my hand and seal on the day and year above written.

SEAL

NOTARY PUBLIC

My commission expires: _____