Distance Education Programs Form

Fields in red are required.

Mr. Ms. Mrs. Miss

Surname
First Name
Middle Name

Street Address
City Province/State Postal Code/ZIP
Residence Phone Business Phone Fax Number

Email Address

CHOICE OF PROGRAM (Please select one)

Advanced Studies in Critical Care Nursing (choose one stream)

Critical Care   Emergency   Neuroscience

Advanced Studies in Perinatal and Neonatal Nursing (choose one stream)

Perinatal   Neonatal

Forensic Studies

Internet Based

Studies in Aging (choose one stream)

Aging   Entrepreneurship


BACKGROUND INFORMATION

Place of Employment/Volunteer

Occupation

Professional Experience

Educational Background

How did you learn about this program? Please check all that apply.

Employer

Program Brochure

Ad in Professional Journal (please specify)

Website

Colleague

Faculty Member

Other (please specify)

     

Freedom of Information and Protection of Privacy Act Section 33(c) as per RSA 2000
The information that you provide is collected under the authority of the Alberta Post Secondary Learning Act and Freedom of Information and Protection of Privacy Act Section 33(c) as per RSA 2000. It will be used to determine your admissibility to this program, for contact purposes and to inform you of other related programs. Your personal information is protected by Alberta's Freedom of Information and Protection and Privacy Act and can be reviewed on request. If you have any questions about the collection or use of this information, contact the department at 403-440-6755.