College of Nursing

Continuing Nursing Education
 
 

LPN INDEPENDENT STUDY REFRESHER COURSE
REGISTRATION FORM

DATE: __________

NAME: (PRINT) _________________________________________________

ADDRESS: ________________________________________________

CITY:                                    STATE:               ZIP: 

Email  _______________________________

TELEPHONE: HOME                                  WORK __________________

RETURN THIS FORM AND A CHECK for $400 or CREDIT CARD Information for billing. If requesting the CDROM method, include an additional $20.00 to purchase the printable CD of the course workbook that you may have printed locally.  

 Credit Card # 

 Exp. Date: 

Methods: Check wish method you wish to utilize for your education. 

1. Online ( ) with written proctored examinations

2. Online ( ) with online examinations

3. CDROM ( ) with online examinations

 

Legal Questions

Please answer the following questions.  If you answer “yes” to any of the questions, please provide a complete description of dates and circumstances on a separate piece of paper.  You must attach supporting documents that are applicable.

A. 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)? 
YesNo

B. Is there any pending criminal prosecution against you which would constitute a felony?
YesNo

C. 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 practice as a nursing student would be impaired?
YesNo

D. 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?
YesNo

(Questions from South Dakota Board of Nursing Licensure Form)

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 in the Refresher Course, I will report the offense to the Coordinator, Continuing Nursing Education in the College of Nursing.

List ALL of the States in which you have been licensed:

1.

2.

3.

 

 

RETURN TO:  Independent Study Refresher Course
                       College of Nursing-Continuing Education
                       Box 2275
                       South Dakota State University
                       Brookings, SD 57007-0098

 

Last Update March 2008
Questions regarding Content or Examinations should be 
addressed to Linda Kropenske @ (605) 688-5745, Coordinator, Continuing Nursing Education

Questions regarding enrollment into the any of the courses should be addressed to
Tammy Herold, Program Assistant @ (605) 688-5745 or FAX to (605) 688-6679 
South Dakota State University

Continuing Nursing Education