CSAD 129: Audiometry and Hearing Screening for School Nurses Course Interest Form

Please answer the questions below, to assess your eligibility for the course.

Please note: * (asterisk) Indicates a required field.

Contact Information

Name:

First Name

Last Name

Birthdate:

Current Student?:

Are you a current Sac State Student?

Yes -If yes, what is your student ID number?:

Sac State Course:

Have you ever taken a course at Sac State?

Yes

If yes, is your current name the same name you had when you were last a student?

Yes

No -If no, what was the name used?:

Address:

Mailing Address

City

State

Zip Code

Email/Phone:

Email Address

Phone Number

Employer/RN/SN Information

School District:

What school district do you currently work for?

RN License:

What is your RN license number?

SN Credential Expiration:

*What is your School Nurse (SN) preliminary credential expiration date?

SNC + MSN Enrollment:

*Are you currently enrolled in the SNC + MSN program through Sacramento State?

Yes

Privacy Policy:

The College of Continuing Education respects your right to privacy. Any information given to us when requesting course or program material will be used solely for the purpose of answering or responding to your request. We do not sell or otherwise distribute your personal information. We may, however, use it to provide you with advanced notices of our course offerings. If at any time you wish to be removed from our mailing lists, you may contact us and your request will be processed immediately.