Purdue University Calumet
School of Nursing
Nursing Distance Education Orientation

Contact Information and Acknowledgement Form

Instructions:  We need to have your contact information and the acknowledgement that you have completed this distance learning orientation for our records.  Please respond to each item in the area below by clicking in each box and either typing in the requested information or clicking on the appropriate choice.  Thank you.

1.  Full Name?

    

2.  Student ID number?

    

3.  Complete mailing address?

    

4.  Complete e-mail address?

    

5.  Home telephone number (including area code)?

    

6.  Today's full date?

    

7.  Please acknowledge your full understanding of what is required of you, now that you have completed this distance education orientation, by clicking on the box that corresponds to yes.  Your Contact information and Acknowledgement Form will be placed in your file as a verification of your required attendance in the nursing distance education orientation.

Yes