Mailing Address (include street address, city, state, zip) *
Your answer
Are you an RN or APRN with at least 1 year of RN experience? *
Employer AND Department: *
Your answer
If you have already registered as a learner with TeleSANE enter your RN(SANE) Student ID#. ***If you do not remember your Student ID# you can still submit the form***
Your answer
City of Residence: *
Your answer
Will you need lodging for April 23, 24 & 25 in Little Rock? (if you plan to share a room with another attendee, please let us know so that we can reserve rooms accordingly)
Clear selection
Do you require a disability accessible room?
Clear selection
Do you have any dietary restrictions or food allergies? If yes, please list.
Your answer
Do you plan to, or hope to, practice in the role of a SANE? (If all 40 spaces in the course are filled, preference may be given to those who plan to use this course knowledge to practice as a SANE over those who do not) *