Nursing Remediation Enrollment Form

Full Name *

Email *

Address

Street Address

City

State

Country

Postal Code

Phone *

Emergency Contact Name *

Emergency Contact Relationship to You *

Emergency Contact Number *

Date of birth *

Name of Nursing School Attending or Attending *

Graduation Date *

Courses available

Licensed Practical Nursing (LPN) Remedial Course

Course consist of Assigned Online Coursework

Weekly Zoom Check-In Every Thursday from 6:00pm - 7:00pm

On-Site Clinical 4 Days 7:00am - 4:00pm

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Registered Nursing (RN) Remedial Course

Course consist of Assigned Online Coursework

Weekly Zoom Check-In Every Thursday from 7:00pm - 8:00pm

On-Site Clinical 4 Days 7:00am - 4:00pm

Please select the your desired enrollment option: *

Licensed Practical Nursing (LPN) Remedial Course Option

Registered Nursing (RN) Remedial Course Option

Please Choose your Start Date for LPN Course

7PM - 8:30PM for Initial Class (First Thursday of the Month) 6pm - 7pm every Thursday for Zoom Call (EST) except for the first Thursday of the month

Please Choose your Start Date for RN Course *

7PM - 8:30PM for Initial Class (First Thursday of the Month) 7pm - 8pm every Thursday for Zoom Call (EST) except for the first Thursday of the month

Which admission scenario/criteria applies to your situation?

1. Applicants who have failed the NCLEX three consecutive times will require a letter to begin the remedial course.

2. Applicants who do not hold an active license and have not practiced in the past five years, and are applying for licensure by endorsement based on having previously passed the State Board Test Pool Examination (SBTPE) or the NCLEX, will require a letter of authorization to complete the clinical component of the remedial course. An authorization letter is not required to begin the theory component of the remedial course.

3. Applicants who passed the NCLEX more than five years ago and were not issued a license, would be required to complete an approved remedial course in order to be issued a license (Rule 64B9-3.014, Florida Administrative Codes (FAC), effective April 10, 2022)

Other

Please put your admission scenario/criteria here.

Applicants who have failed the NCLEX three consecutive times will require a letter to begin the remedial course. Upload Florida Board of Nursing Remedial Letter

Please Upload your Drivers License/State ID Card *

Copy of BLS Card , Can be from American Heart Association or American Red Cross. No other cards will be accepted.

PPD test (TB Skin Test) lab result or chest x-ray (Must be negative within the past year)

Student Liability Coverage

1 Million Dollar coverage/ $43 a year This is a recommended site, but you can use other companies. Please upload your active policy. https://www.nso.com/malpractice-insurance/individuals/nursing-students

TUITION & FEE INFORMATION

There are two payment options:

1st Option: Full Payment Option of $2,005.00

2nd Option:

Deposit: $705 Non-Refundable, Included in Total Program Cost

2nd Payment: $650.00 Due by Week 4 of Course

3rd Payment: $650.00 Due by Week 8 of Course

Total Course Price: $2,005.00

All payments are Non-Refundable

Payment Plans through PayPal Credit, Affirm, and Afterpay!

***Please Note: Students will not be able to complete clinical or the program without the tuition being paid in full on Week 10. If clinical is missed during your scheduled course, clinicals will not be offered again until the next course which may be in several months.

Would you like to pay with one of Paypal Credits, or Affirm?

Yes

No

Which payment option would you like to go with? *

1st Option (One-Time Full Payment)

2nd Option (Multiple Payments)

Clinical Practicum

The Remediation course has contracted Nurse Resource Training Center to secure clinical preceptorship hours for students at Pruitt Healthcare - Southwood (Tallahassee, Fl), Doctors Memorial Hospital (Perry, Fl) and Villas at Killearn Lakes (Tallahassee, Fl), shifts may vary but expect to spend up to 12 hours per clinical day.

You also have the option of securing your own preceptorship and facility placement. Please see below

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A Clinical and Preceptor Agreement must be signed by the appropriate facility administrative representative and returned within 4 weeks of clinical. If a student elects to locate their own preceptor and site, they will not be able to start for the class until this agreement is completed and returned to the NRTC’s nursing office.

Please note: A more detailed description is in the attached Enrollment Agreement.

Preceptors must email the following to [email protected]:

Signed NRTC’s Preceptorship Agreement

Current Resume

Proof of Active Florida License

Do you plan on using Nurse Resource Training Center's Clinical Sites or Do you plan on finding your own clinical site? Please note, the site must be in the state of Florida. *

I will use Nurse Resource Training Centers Clinical Sites

I will find my own Florida-based clinical site and have the Clinical and Preceptor Agreement signed by 4 weeks before the scheduled clinical dates.

I'm not sure

Signature *

Clear

By signing above, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on the linked Agreement. By typing your electronic signature you consent to be legally bound by the linked Agreement's terms and conditions.

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