If 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. 

BEFORE YOU FILL OUT THIS FORM:  Please read our website concerning what we consider to be disciplinary issues.  Click the Nurse Refresher link, and then Open Enrollment Policy.  Email us at info@learningsvc.com with any questions/concerns before you enroll.   

It is your responsibility to check with the BON in the state you wish to be licensed to see if they will reactivate your license.    All states have different policies.   Do this BEFORE you register and pay for this course.   If you are straddling state lines, please feel free to email us and we can work with you on the best route to get relicensed. 

 Consolidated Learning Services

Nurse Refresher Course Enrollment Form

Today’s Date:

NAME (if your name on your license is different, please indicate)

ADDRESS, including city, state and zip:

Phone number: 

Email address: 

Please check the appropriate box: 

Complete the next box only if you were an LVN/LPN: 

Only complete if you have NEVER held an RN license in the USA:

 If you have returned to school, please indicate, check all that apply:  

Please place a checkmark under any of the courses that you have had for undergraduate college credit.    CLEP exam does count.  These are separate courses from the nursing curriculum.  Do NOT check the box if the information was integrated into your nursing curriculum. 

***If you have not had any course for college credit, it does not prevent you from taking this refresher course.  You are expected to read, write, and articulate yourself at a college level. 

Please indicate: 

Please mark any areas of nursing where you have had at least one year full-time experience: 

 If other, please list:

For clinical rotations, we will make suggestions that fit within areas you are familiar with and/or have worked.  There is no guarantee that you will find clinical in the area that you desire.  

You may return this form by email attachment or pasted into the body of an email to info@learningsvc.com or send via regular mail.  Payment is to be made at time of enrollment.  Enrollments without payment will be cancelled.  You may use Paypal (button below) or print the enrollment form and mail a check.  Do NOT just mail a check with no identifying information.  First module is sent within one business day after payment clears.   

Please read the Student Handbook and the website prior to enrollment.  Email us at info@learningsvc.com with any questions or concerns prior to enrollment and payment of the course.   This payment is for theory only.  The button for clinical payment is separate at the bottom of this page.  

Consolidated Learning Services,  7410 River Road; Fredericksburg, VA 22407

PAYMENT FOR CLINICAL PORTION OF THE COURSE

Information gathered from the enrollment form is used for statistical purposes to further nursing research and/or to improve the quality of this course.  Your personal information is NEVER disclosed to anyone without your permission and NEVER leaves the office.  Any copies of the enrollment form have all personal information redacted by our office staff prior to usage for statistical purposes. .