Application

Application
Name

First NameLast Name
Today's Date

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What course are you taking?
Insert a copy of your government ID here (DL, Passport, etc.)

Cancelof
Insert a copy of your License here (RN, LVN, NP)

Cancelof
By signing this agreement, I certify that:
1. I am a licensed healthcare professional (RN, LVN, or NP) and the license information I provided is accurate and current.
2. I understand that this course is a Continuing Education (CE) program and is not an academic degree or licensure program.
3. I understand that CE credit is awarded only after completion of all required course components, including online theory, hands-on lab participation, return demonstration (if applicable), and course evaluation.
4. I acknowledge that this course is approved by the Montana Nurses Association (MNA) and follows ANCC continuing education standards, and that acceptance of CE credit may vary by state board of nursing or employer policy.
5. I understand that no CE certificate will be issued if I do not complete all required components of the course.
6. I agree that it is my responsibility to verify CE acceptance with my state board of nursing or employer if required.
7. I understand that course fees are non-refundable once the course has started, unless otherwise stated in writing by DMS Care Training Center.
8. I consent to the use of my information for CE documentation, certificate issuance, and regulatory recordkeeping purposes.
9. I understand that participation in hands-on skills training and lab activities involves the use of medical equipment, supplies, and simulation devices. I agree to follow all safety instructions and instructor guidance at all times.
10. I acknowledge that I am personally responsible for any damage, loss, or misuse of equipment, supplies, or property caused by my negligence, failure to follow instructions, or unsafe behavior during hands-on training or lab sessions.
11. I understand that DMS Care Training Center is not responsible for personal injury resulting from failure to follow safety guidelines or instructor directions during skills practice.
12. I agree to immediately report any accident, injury, or equipment damage to the instructor or staff.
Signature
Should be Empty: