312 West Georgia Street, Floydada, Texas 79235 Phone/fax (806) 983-8096 coordinator@ruralnurseresource.com
Basic Parish Nurse Preparation Course Application 2010
Course start date/location ___________________________ Parish Nurse ___ Health Advocate ___
TYPE OR PRINT CLEARLY Please fill in all information completely.
NAME:________________________ ________________________ _______________________
Last First Middle
Last 4 numbers of Social Security #: ___________ Date of Birth: _____________ (for file identification)
Telephone: ___________________ Email: _____________________________________________
Address:__________________________________ City _________________________ Zip ____________
Nursing License state and # __________________________ What type of nursing education do you have?
___ Diploma ___ AD ___ BSN ___ MSN ___ other/additional education, certification, or degrees
_________________________________________________
For Health Advocates: __ retired RN __ LVN __ other please specify ______________________________
In case of emergency, please notify:
Name: _______________________________ Phone(s):_______________ Relationship: ______________
Are you receiving financial assistance to attend this class? ___ YES ___ NO
If yes, from whom?
Are you currently practicing as a parish nurse/health advocate? ___ YES ___ NO
What is your current and any previous denomination/faith community? __________________________
________________________________________________________________________
How did you find out about this course? __________________________________________________
I certify that the information provided in the above application is true and correct. I understand that false information on this application may result in immediate removal from the course with no refund.
Signature Date
Return entire application including attached question responses and letter of recommendation from your clergy or denomination/organization representative.
Note: Students not enrolling in the class start date noted at the top of this application must submit a new application to be considered for another class start date. Tuition must be paid in full 10 days prior to course start date. Paid tuition minus a $75 processing fee will be refunded if the applicant notifies the course coordinator in writing of withdrawal two days prior to the course start date. NO REFUNDS will be given after the course start date. Transportation, housing, and meals are the sole responsibility of the participant unless the course announcement specifically states one or more of these are included in the tuition. RNR assumes NO responsibility for travel costs incurred should a course be canceled.
Note: Only registered nurses with current, valid licensure in good standing are eligible to receive continuing education credits, IPNRC certificate and pin. Other participants will receive a health advocate attendance certificate and pin.
PLEASE TYPE OR WRITE CLEARLY RESPONSES TO THE FOLLOWING QUESTIONS. Use additional paper as needed. Your answers will only be shared with the coordinator and instructor of this course.
1. Briefly list work, church, and volunteer projects and responsibilities in which you have participated that have helped your ability to be a parish nurse. Include volunteer positions in community, school, etc. Describe why you were involved and what you accomplished.
2. Briefly discuss other life experiences that have contributed to your ability as a nurse and/or personal-spiritual growth which adds to your ability as a parish nurse.
3. How will you use the knowledge and experience gained from attending this course? If you don’t already have a position, describe one you would want. *There is no requirement that you have a position as a parish nurse to take this course.
4. Write anything else you would want the instructor to know in order to customize this course to what you want and need so that you consider this course a success. Include any questions you may have at this time.
RNR™ Rural Nurse Resource, Inc
312 West Georgia Street, Floydada, Texas 79235 Phone/fax (806) 983-8096 coordinator@ruralnurseresource.com
Basic Parish Nurse Preparation Course Accommodation Form 2010
NAME: . Date of Birth ____________
1. Are you presently in good health?__________ If not, list any physical accommodations needed during this course ___________________________________________________________________________________ _________________________________________________________________________________________
2. Do you have any serious illness, injury, or allergy that we need to be aware of for your safety? ___________ If yes, please list ______________________________________________________________________________
__________________________________________________________________________________________
3. Are you currently taking any medication that we need to be aware of? __________ If yes, list ____________________________________________________________________________________________________________________________________________________________________________________
4. Do you have any dietary needs we should be aware of? ______ If yes, please explain accommodations needed. ____________________________________________________________________________________________________________________________________________________________________________________*NOTE some courses may be served pot luck dishes from the host congregation: we cannot guarantee content of these dishes. Please use discretion if you have allergies.
5. Is there anything else we need to know to make this course safe and enjoyable for you? __________________ ____________________________________________________________________________________________________________________________________________________________________________________