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Long Term Care Registration

This form is designed to be completed by the frontline nurse who will be participating in the course. Please ensure you have received approval from your manager that you are supported to participate. Your manager will also be given access to the Manager’s Leadership Guide to help them support you, so please include their information at the bottom of this form.

Note for managers: If you are completing this form on behalf of a frontline nurse, please ensure you have their consent, and that you fill in their information in the top portion of the form, and your own information near the bottom.

Frontline Nurse's Information

First Name (as it will appear on all correspondence and/or official documents):

Last Name (as it will appear on all correspondence and/or official documents):

Preferred Name:

Address:

County:

City:

Province:

Postal Code:

Preferred Contact Number: (Please provide the phone number we can best contact you)

Work Phone Number:

Work Number Extension:

Email: (Please provide the email address that you check most frequently. This is our most frequent method of correspondence.)

Please Confirm Your Email:

Professional Designation: (Please choose a designation from the dropdown below) (RN or LPN)

Health Zone: (Please choose a health zone from the dropdown below) (just use the 4 zones in NSH)

Current Employer/ Company Name:

Building Name/ Campus and Wing/ Floor/ Unit:

Manager's Information

Immediate Manager:

Immediate Manager Email:

Immediate Manager Phone Number:

Immediate Manager aware of the need to participate as a sponsoring manager

Course Start Date: (Please choose a date from the dropdown below) (to be determined)

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The Nova Scotia Health Learning Institute for Health Care Providers offers education programming designed to meet the needs of learners across the province and strengthen our health care system. We are committed to delivering high-quality, evidence-informed programming that enables providers to develop and maintain foundational and specialty competencies.