The University of North Carolina at Wilmington
School of Nursing

RN ACCESS PROGRAM

NSG 389
Family Visit Consent Form


I agree for a registered nurse student from the UNCW School of Nursing RN ACCESS Program to visit me and my family in our home from September through November 1997.

I understand any information I share with the student will be considered confidential.

I and my family reserve the right to withdraw from this student home visit experience at any time.



_____________________________ _____________________________
Family Member Signature Student Signature
_____________________________ _____________________________
Date Date

Distribution List: Family Member RN Student Course Coordinator
Nursing Faculty Member to call regarding questions:

P. Allen Gray, Jr., RN, PhD
Director, RN ACCESS Program
910-962-7292 * gray@uncwil.edu

last updated: 29 AUG 1997