Student Registration Request Form

Student Name

First Name *

Last Name *

Student Job Title (Required)

Student Phone (Required)

Student Email (Required)

Student Date of Hire (Required)

Agency Name (Required)

Agency Contact (Required)

Agency Phone (Required)

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Agency Email (Required)

Please enroll student in the following course: (Required)

Training Date (if multiple days, select start date)

Month

Day

Year

*Please check the dates the training is offered.

Continuing Education Course Name

Does your student require ASL interpreters? Please check the appropriate option:

Yes - My agency will schedule and pay for all interpreting services, and provide this information to PSRS
*Yes - Please schedule an ASL interpreter for the student
No Interpreter

*PSRS frequently schedules ASL interpreters for trainings. If you have requested that PSRS schedule the interpreter, you agree to be responsible for a portion of, or all of the payment depending on the number of Deaf students. Payment will be based on the number of total Deaf students divided by the number of training days.

Do you require any accommodations we should know about?

Please Note: You are submitting a training request. PSRS gives priority to our staff, and may not have availability in the class you wish to register for. You will receive an email from the PSRS Training Team soon containing more information about the status of your request.

Nurse Delegation Core Training Cancellation Policy

Any cancellations must be made at least 72 hours in advance of the scheduled class, or you may subject to a $75 cancellation fee. Student substitutions may be made up to 24 hours prior to the class to prevent the cancellation fee. This fee will be invoiced to the agency and contact indicated on the registration request form.