Leadership Course for LPNs

Fields marked with an asterisk (*) are required

Personal Information

Complete all spaces below. Use N/A if required.

First Name*:

Middle Name(s):

Last Name*:

Registration Number*:

Email Address*:

Date of Birth*:

Street Address:

City:

Postal Code:

Phone Number*: HomeCellWork

Secondary Phone Number: HomeCellWork

Years as an LPN*:
5 or less 6-10 11-19 20 or more

Primary Place of Practice*: Acute Care Mental Health Long Term Care Management Rehabilitation/ Restorative Community Other (Please specify)

Other:

Employment District*: 1 South Shore 2 Valley 3 Halifax 4 Pictou 5 Cape Breton 6 Cumberland

Course Information

This course is an open access and self-directed online learning module. You will need access to a computer and the internet to complete this course. The course begins on the 1st of the month and you must register by the 10th of the month previous. Once registered and all fees are paid*, you will be sent an ID and login information. Your ID and login will be only valid for 6 months. If you need additional time to complete the course, you must submit a Request for Extension Form to CLPNNS. An additional processing fee may be applicable.

*Course work cannot begin until all fees are paid.

Month you wish to start?* February March April May June July August September October November December

All courses begin on the 1st of the month. You must register by the 10th of the previous month

Planned payment method: Cash (including cheque)Credit Card (Visa or MasterCard only)

Details on making payment arrangements will be sent to you by e-mail once your registration is complete.

Declaration

I certify I am the person named above, the information is true and accurate and I have read and understand the Leadership for LPNs Frequently Asked Questions document online.

e-Signature*:

Date*:

Please type the characters and/or digits you see in the box below.