ReNurse Academy RN/LPN Refresher Course Application

ReNurse Academy RN or LPN Clinical Course Application
Which clinical course are you applying for ?*
Please select your discipline:*

RNLPNOther
Have you attended or registered for any other ReNurse Academy Courses*

YesNo
Admission Requirements

Participants are required to meet clinical requirements prior to attending their clinical experience. Clinical experiences can be held in various clinical settings

Participants will be required to open a Castle Branch account to ensure preclinical and post clinical requirements are met.

Participants taking the virtual clinical experiences are NOT REQUIRED to open a Castle Branch account.

Conditional Admission

Admission to the in-person clinical portion of the refresher course is conditioned on the results of the background checks completed through Castlebranch.

If a prospective participant has been convicted, pled guilty or no contest to, or received a suspended imposition of sentence for a felony or other criminal offence, the participant is advised it may not be possible to be accepted into the refresher course at ReNurse Academy. Participants may be denied reinstatement from their state Board of Nursing, from taking the required licensure exam, and/or may be prevented from gaining employment in the field of nursing.

NOTE: Prospective participants whose background search indicates a prior felony conviction may not be accepted for the refresher course.

Participant Information
Name*

First NameLast Name
M.I.
Birth Date *

MonthDayYear
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.
If yes, what year?*

RN or LPN School Information
School Name*
City
State*
Other: Please describe
State not listed? Please provide.
Date Started

MonthDayYear
Date
Date Graduated*

MonthDayYear
Date
Check all that apply:

Inactive license reapplying for nursing licenseActive license, seeking to refresh knowledge and clinical skillsAway from active nursing for _________yearsA nurse who has been directed by the State Board of Examiners for Nursing (BOEN) to complete a refresher courseOther
List how many years you've been away from active practice *
Other*
Please list why you are taking this course
List all of the states in which you have been licensed and indicate the current status: if you never received a license put N/A*
Please include if the license is ACTIVE or INACTIVE
Years of Nursing Experience*
Explain your primary practice areas of nursing. Include type of setting, years of work and any specialty areas: *
This can include any experiences worked in healthcare. Put N/A if none.
Legal Questions

Please answer the following questions. If you answer Yes to any of the questions, provide a complete description of the dates and circumstances. You must provide supporting documents that are applicable.
Have you ever been convicted, pled guilty or no contest, or received a suspended imposition of sentence for a felony or other criminal offense (excluding minor traffic violations)? *
Is there any pending criminal prosecution against you which would constitute a felony?*
Within the last three years, have you been treated for abuse or misuse of any alcohol or chemical substance to the extent that your ability to safely participate in this course would be impaired? *
Within the past three years, have you experienced a physical, emotional, or mental condition that has endangered the health or safety of persons entrusted in your care? *
I understand that if I am convicted, plead guilty or no contest, or receive a suspended imposition of sentence for a felony or other criminal offense (excluding minor traffic violations) while enrolled in the Refresher Course, I must report the offense to ReNurse Academy.*
If you answered yes to any of the above legal questions, please provide details below
You will be required to provide supporting documentation for each occurrence.
Course Enrollment Readiness Review

If you answer NO to any of the statements below, contact the ReNurse Academy at contact@renurseacademy.com to review the requirements and your application.
I understand that I MUST opened an account with Castle Branch in my legal first and last name as recorded on this application and request the two background searches required for enrollment to begin. I understand my application may be received, but not accepted until the results of both background searches are accessible by ReNurse Academy. (For In-Person Clinical Participants)*
I will provide verification of my past or present nursing license, available at Nursys (select Quick Confirm). If your state does not participate in Nursys, you may obtain verification from each state Board of Nursing in which you were/are currently licensed. *
I have reviewed the Individual Clinical Experience Overview located on ReNurse Academy's website. *
In preparation for clinical, I acknowledge that Castle Branch will be my document manager. (For In-Person Clinical Participants)*
You MUST submit all required documents to Castle Branch for complete acceptance into the course. There is $144 fee paid directly to Castle Branch.
Place a check next to each statement as acknowledgement of the course requirements*

I understand that if I register for a Virtual Clinical Course I am not required to complete the pre-clinical castle branch requirements.I am aware that I must complete and pass both a criminal background and drug screening prior to acceptance. (For In-Person Clinical Participants)I am aware that attendance for all scheduled class times are mandatoryI am aware that I must have up to date- CPR training for Professional rescuer or Health Care Provider prior to the first day of clinical (For In-Person Clinical Participants)I am aware that I must meet the health care requirements completed through Castle Branch (physical exam, 2-step TB skin test, COVID Vaccination, Tdap, MMR, Varicella, and Hepatitis B series or wavier prior to the first day of clinical) (For In-Person Clinical Participants)Refund Policy: I understand that I have 48 hours after submitting this application to request 50% of the Course fee. If I receive my course materials and decide against continuing, a refund will not be granted.I hereby verify that all of the information contained in this document is accurate and truthful to the best of my knowledge.I attest that I understand the Course Requirements and are capable of meeting ALL of the requirements prior to applying.
Signature*
Date*

MonthDayYear
Date

You are required to submit a payment with your application. Please see details below:*

Application FeeThere is a $50 non-refundable application fee. This fee will be used to process your application.

$50.00

Clinical Experience (ONLY) :Use the drop down menu to choose which clinical course you wish to apply for. NOTE: Clinical is included in the Refresher Full Courses. This option is ONLY for those looking to get additional clinical experience.

$1,250.00

Enter coupon

Total

$0.00

Credit Card

You certify that the information in this application is valid and you authorize ReNurse Academy and its' affiliated institution to process your payment and application.*
Should be Empty:

ReNurse Academy RN or LPN Clinical Course Application

Legal Questions

Course Enrollment Readiness Review

Credit Card