Application for Admission

In addition to applying for admission to the Nurse Re-Entry Program, you will need to apply to the Oregon State Board of Nursing for licensure or re-activation of your license.

To apply for our Nurse Re-Entry program, please complete the application for admission below and submit payment for program costs.

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Application for Admission
Name
Address
City, State, Zip
Date of Birth
Phone Number
Referred By
Year Graduated from Nursing Program
Degree Attained
Year Last Practiced Nursing
State Orginally Licensed
State Last Licensed
Date Applied to OBSN for Re-Licensure
Attach a brief history of your nursing work experience (with dates) or enclose a professional resume
Upload
Nursing specialty or area of interest
Clinical Facility of Interest
Clinical Facility Address of Interest
Clinical Facility Contact of Interest
Has your license to practice nursing ever been suspended or revoked, or have you ever been reprimanded?
If "Yes", please provide a brief explanation
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Waiver and Release Agreement

In consideration of the undersigned student participating in any program offered by Health & Educational Consultants, Inc., the undersigned student hereby waives and releases any and all claims the undersigned (and other persons as provided below) may have at any time against Health & Educational Consultants, Inc.(and other persons as provided below) for any and all injuries to the person of the undersigned (including but not limited to those resulting in death) and damage to property of the undersigned, arising from any act or omission:

            (1)       Of any hospital or other institution in which the undersigned may engage in any instruction, practicum, or other activity pertaining to any nursing education in which Health & Educational Consultants, Inc. is involved;

            (2)       Of any person in any fashion employed or otherwise associated with such hospital or other institution (including but not limited to the physicians and any other members of the medical staff thereof); and

            (3)       Of any person who is a patient or in any fashion is in or at such hospital or other institution.

The foregoing waiver and release is for the benefit of Health & Educational Consultants, Inc. and its successors and assigns, and its owners, officers,employees, and agents.

The foregoing waiver and release is binding upon the undersigned and the undersigned's heirs, devisees, personal representatives, and assigns.

This waiver and release has been prepared by attorneys for Health & Educational Consultants, Inc. and the undersigned has had the full right and opportunity before signing this instrument to obtain the advice of any attorney chosen bythe undersigned concerning the legal effect of this instrument.

I agree to the Waiver and Release Agreement
Signature
I confirm that I am the individual as indicated herein, and consent an electronic signature confirms my approval
Electronic Signature
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