Nursing & Health Sciences

Course Request Form: Re‐entry Students

 

Today’s Date:_______________________      Request re‐entry for:     Fall       SP     SU     Year_________                  

Student Name______________________________________     Student ID_________________________

Contact Information:   Phone:__________________________   LCMail:___________________________

Courses Failed:          

Course Name Semester/Yr Grade Instructor(s)
       
       

Academic Plan for returning semester (see policy for requirements):

⃝  Basic Skills Testing                                     ‐or‐              ⃝   Clinical Course:  List_________________    

⃝  Failed course (Skills Refresher or Clinical not required if retaking clinical due to failure): List:

_____________________________________________________________________________________

⃝   Clinical theory course:  List:___________________________________________________________  

 

Advisor Information:

Comments:____________________________________________________________________________

_____________________________________________________________________________________

⃝ Narration from student attached                  ⃝  Re‐entry application  attached          ⃝   Fee paid

 ⃝ Certified profile attached.                           ⃝  Basic Skills registration  attached            

⃝  Immunization, CPR, background check are in compliance

Student signature_________________________________________________________Date_________

Advisor Signature_________________________________ Printed Name__________________________

Program Chair Signature________________________________________________Date_____________