|
First Name
|
|
Yrs in School Health
_____
|
|
Last Name
|
|
|
|
Degree
|
|
BSN Req'd by Dist?
________
|
|
Title
|
|
SN Cert Req'd by Dist?
________
|
|
School Phone
|
|
|
|
School Fax
|
|
|
|
School E-mail
|
|
Mac or IBM PC
|
|
School Name
|
|
# Schools Served
_________
|
|
School Address or P.O. Box
|
|
# Students Served _________
|
|
School City
|
|
Health Asst on campus? _____
|
|
School Zip
|
|
|
|
CO /Dist/ Type/ School
#
|
|
|
|
District Name
|
|
"301": Yes No
|
|
County
|
|
"202": Yes No
|
|
Home Phone
|
|
|
|
Home Fax
|
|
|
|
Home E-mail
|
|
Mac or IBM PC
|
|
Home Address or P. O. Box
|
|
|
|
Home City
|
|
|
|
Home Zip
|
|
|
|
Preschool or
SBClinic
|
|
|
|
SNOA Member
|
New
|
Renew
|
|
NASN Member
|
New
|
Renew
|
|
SN Practice Course
|
|
Date completed
|
|
Care of Dev. Disabl.
Course
|
|
Date completed
|
|
Physical Assmt
Course
|
|
Date completed
|
|
Community Health
Course
|
|
Date completed
|
|
Nsg Prac. Mgmt.
Course
|
|
Date completed
|
|
Other Upper Div
Course
|
|
3 credits; Date
completed
|
|
Contact Hours
|
|
Indicate # within past 6
yrs
|
|
Cert. Exp. Date
|
|
|
