ReNurse Academy LPN Refresher Course Application

ReNurse Academy RN/LPN Refresher (Theory Only) Course Application
Which course are you applying for?*

RN Refresher Course (Online Theory ONLY)LPN Refresher Course (Online Theory ONLY)
Admission Requirements

The refresher course (Theory Only) considers enrollment from prospective participants in the following circumstances:
- Currently licensed RNs or LPNs who desire to refresh their knowledge or skills in the profession, due to time away from practice, or a break from the profession (e.g., for family reasons, other careers, or personal matters)
- Graduate Nurses who have successfully completed an RN or LPN education program who however have not yet successfully completed the NCLEX-RN or NCLEX-PN exam.
- Inactive Nurses that have been away from practice and are required to take the NCLEX Exam again.
NOTE: This course format does not include clinical component.

Participant Information
Name*

First NameLast Name
M.I.
Birth Date *

MonthDayYear
Date
Gender*
Ethnicity
Primary Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Secondary Phone Number

Area CodePhone Number
Current Residence Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing address (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Preferred Hospital
Insurance/Health Coverage (Company)*
Please inform the office of any other vital information you think they may need to know in the event of an emergency.
Have you previously applied to or attended this school?*

YesNo
If yes, what year?*

ReNurse Academy RN/LPN Refresher (Theory Only) Course Application

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