Student Contact

Hello!

If you are seeing this form there is a good chance a SALPN representative is standing in front of you right now watching your every move! 🙂

Please complete the form to send us your contact information. This will allow us to stay in touch with you as you approach the end of your program.

First Name *

Middle *

Last Name *

Maiden Name

Primary E-mail Address *

Personal E-mail Address

Mobile Number *

If no mobile, enter home phone or landline number.

If we have a technological break through, can we send you sms notifications? *

Yes

No

Alternate Number (optional)

Gender *

Date of Birth *

Mailing Address *

Mailing Address

Street Address

Address Line 2

City

Province

Postal Code

Country

Where are you taking the LPN program? (Campus) *

Student Contact Collection Form