RN INDEPENDENT STUDY REFRESHER COURSE
DATE: __________ NAME: (PRINT) __________________________________________________ ADDRESS: ________________________________________________ CITY: STATE: ZIP: Email: _______________________________ TELEPHONE: HOME WORK _____________________ RETURN THIS FORM AND A CHECK for $500 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 which method you wish to use 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)? B. Is there any pending criminal prosecution against you which would
constitute a felony? 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? 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? (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
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