Registration form

To be completed by a faculty member.

Student's name:

Student's e-mail address: @lcn.edu

Estimated graduation month:

May

December

Estimated graduation year:

Completed service hours:

Registration:

Year:

Semester:

Health records verification:

Influenza (required around October of each year)

Tetanus (current within the last 10 years)

Tetanus expires:

Tuberculosis (TB)

TB expires:

Check the box if the student has never attended a Carle facility for clinicals in the past. (TB results must be within 6 months of the first date of attendance at a Carle facility. This is not tracked in Castlebranch, but will be enforced at the beginning of each semester for all students attending Carle facilities for the first time.)

Cardiopulmonary resuscitation (CPR)

CPR expires:

Notes (optional):

Advisor:

CAPTCHA