SWOC Registration Form

SWOC Certification Course

Registration Form

Course Location*

First Name*

Middle Name (optional)

Last Name*

Date of Birth (for identification purposes)*

Mailing Address (use Personal Address, all course materials and certificates are sent here)*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number (personal phone number is suggested)*

Email Address (personal email, please avoid using work email)*

License Type (must be a LVN, LPN, or RN)*

License Number*

Facility or Agency Name*

Position (i.e. TN, DON, DSD, etc.)*

How did you hear about us? *

Have you taken our certification course and examination in the past and need to re certify?*

Pricing*

SWOC Certification Price$1,500.00

SWOC Recert - Entire Course$500.00

Exam Only - Recert or Online Course Student$200.00

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Total $0.00

We ask for personal email rather than work email because we reach out to you directly with all information regarding the course via email, including where the course is located, what you need to bring, and detailed schedules of each day. All course materials and certificates are sent via USPS mail to the address on file, and to avoid any issues with these packages not getting to you in a timely manner, it is best to use your home addres. Lastly, we ask for personal phone numbers because we will call you directly if there are any issues and when it is time to recertify,

All information we collect will only be used internally by The College of Long Term Care and Skilled Wound Care, and WILL NOT be sold nor disctributed to any third party companies.

Please verify that you are human*