CLINICAL REGISTRATION | Nurclex Healthcare

Clinical Registration Form

First Name

Last Name

Birthday

Phone

Are you an LPN or RN remedial student?

LPN Student

RN Student

Upload Picture of ID

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Upload CPR Card (American Heart Association Only )

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PPD Results

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Student Physical

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Upload Picture of Self (Badge)

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10 Panel Drug Screening * If you attending SAT/SUN CLINICALS

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Proof of Immunizations TDAP,MMR,Varciella,Hep B Proof or Declination . All immunizations must be in the last 10yrs . If not please upload your immunization Titers to show immunity . If no immunity is had student must get booster and provide proof .

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