Consolidated
Learning ServicesIf you are unable to type this form online, you may send it as a word attachment in an email or: please go to the top left corner of your screen, hit edit, select all, copy and then paste this form into the body of an email. Fill it out and email it to info@learningsvc.com.
We do not accept enrollment without subsequent payment. If you are sending a personal check, PRINT this form and mail it with your check. You may email us and let us know that you are sending enrollment and check by mail. If you email this form, please use Paypal to pay for the course. Enrollment forms without payment will be cancelled.
Consolidated
Learning Services
7410 River Road; Fredericksburg, VA 22407
Nurse Refresher Course Enrollment Form
Date:
Name as it appears on your license:
Address, including city, state and zip:
Phone number where we may call you with any issues:
Email address which we will use to send assignments:
What is your initial level of nursing training? Please check one
____ LVN/LPN ____ ADN/AA/AS ____diploma ___BSN
What year were you initially licensed? _________ What state or territory? _____
In what state did you hold your last active RN license? _____
***If you are attempting to reactive in a state that is NOT the last state you held an active license, it is your responsibility to speak to the Board of your current state and inquire as to whether they allow reactivation on an out of state lapsed license. In most cases, you can take the refresher theory and then are required to sit for NCLEX.
How many years of full time nursing practice did you engage in prior to becoming inactive? ________ In what area(s
Are you inactive due to a disciplinary proceeding? Yes/NO (Yes answer does not necessarily preclude you from enrollment. We will contact you to further discuss the issues relating to your disciplinary proceeding and the BON recommendations).
Do you have a job in nursing which you will begin after your license is reactivated? If so, name and address of new employer:
You may return this form by email attachment to info@learningsvc.com or print and send by regular mail.
Please read the Student Handbook prior to enrollment. Email us at info@learningsvc.com with any questions or concerns prior to enrollment and payment of the course. Payment may be made via Paypal online at this time or you may print the invoice and mail a check. First module is sent after payment clears.