We understand that life happens and there may be a need to change your contact information while you are waiting for enrollment to a nursing program or are currently enrolled in the ADN, LVN or Nurse Aide program. (This form is only to be used if you have a Wait List Number issued to you for a specific program or are already enrolled in a class).  Without current information, we will not be able to communicate with you and you may miss an important deadline which could cause you to be delayed in entry or even removed from the list. 

If you are notifying us of a name change, please indicate your previous last name in the Formerly Known As box.

 

CURRENT Contact Information

 

* Program	(Select One) Associate Degree Nursing LVN-RN Transition Vocational Nursing Nurse Aide/Home Health Aide
* Full Name:	Formerly known as:
* Address:
* City:
* State:	(Select) Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas (except Canada) Armed Forces Europe, Canada, Africa, Middle East Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
* Zip Code:
* Primary Phone:
Alternate Phone:
Email Address: