APPLICATION CHECKLIST ASSOCIATE OF APPLIED SCIENCE REGISTERED NURSING

Transcription

1 APPLICATION CHECKLIST ASSOCIATE OF APPLIED SCIENCE REGISTERED NURSING AND LPN TO BSN Before applying, please check the minimum requirements for this program. Applicants who do not meet the minimum eligibility requirements will not be admitted. Please review the lists below to ensure that all required documents are submitted. The items in the left section are items to submit with the application which can be mailed or dropped off during regular business hours. The items in the right section should be mailed (not faxed) by the individuals or organizations submitting the documents and should be mailed directly to: Admissions Office 2001 William Street Cape Girardeau, MO Applicant should submit with application: Individuals or organizations sending these items should mail them directly to College: Basic Nursing applicants must submit: Fully completed Application Form $100 Application Fee Copy of valid Photo Identification Medical History Form Immunization Records Background Check Form Official High School or high school equivalency transcript Official transcripts from all colleges, universities, and vocational schools attended One of the following: ACT scores taken less than 5 years ago ATI TEAS scores (if age 23 or older) LPN to RN and LPN to BSN applicants must submit: Fully completed Application Form $100 Application Fee Copy of valid Photo Identification Medical History Form Immunization Records Background Check Form Copy of LPN license (unless still in progress) Official High School or high school equivalency transcript Official transcripts from all colleges, universities, and vocational schools attended NLN Nursing Acceleration Challenge Exam (NACE) I Scores Paramedic to RN applicants must submit: Fully completed Application Form $100 Application Fee Copy of valid Photo Identification Medical History Form Immunization Records Background Check Form Copy of Paramedic License Paramedic Work Experience form Official High School or high school equivalency transcript Official transcripts from all colleges, universities, and vocational schools attended One of the following: ACT scores taken less than 5 years ago ATI TEAS scores (if age 23 or older) Copy of valid photo identification includes any U.S. state or federal photo identification. Immunization records and ACT scores may be included with high school transcripts. Complete only the highlighted sections of the background check form and return form to College. The fees for the background checks are included in the $100 application fee. ATI TEAS exam may be taken at the Cape Girardeau Career and Technology Center, extension All items listed above must be received before the application will be reviewed. It is the applicant s responsibility to make sure items are received. A week or two after submitting your application you will receive an with instructions on how to access our database to view the missing checklist items and the current status of your application. Southeast Missouri Hospital College of Nursing and Health Sciences is accredited by the Higher Learning Commission, 230 South LaSalle Street, Suite 7-500, Chicago, Illinois Phone

2 APPLICATION FOR ADMISSION A $ fee is required to process this application. It is nonrefundable 3 business days after submission. If you are applying for more than one program, a separate application and application fee are required. Please print clearly and complete every section. First Name Middle Name Last/Family Name Previous Names (if applicable) Mailing Address City State Zip County Permanent Address (if different from above) City State Zip County Home Phone Cell Phone Work Phone address (correspondence regarding admission will be directed to this address) For which program are you applying? (see separate page for admission requirements) Certificate in Clinical Laboratory Assistant (begins in Fall) Certificate in Surgical Technology (begins in Summer) Associate of Arts (Emphasis: Allied Health) (begins any semester) Associate of Applied Science in Radiologic Technology (begins in Summer) Certificate in Medical Laboratory Science (bachelor s degree required) Spring start Fall start Associate of Applied Science in Nursing (select the track you prefer under the option for which you are eligible): Basic RN tracks LPN Bridge tracks Paramedic to RN Bridge track Full-time (begins in Summer) Accelerated (begins in Summer) Part-time Monday/Thursday Part-Time Evening/Weekend (begins in Fall) Part-Time Evening/Weekend (begins in Fall) (begins in Fall) First Available LPN to BSN (accelerated, begins in Summer) First Available Bachelor of Science in Nursing (must be an RN or nearing completion of an RN program) RN to BSN Accelerated RN to BSN What is the earliest date you would like to begin classes? Have you previously applied for admission to this College? Yes No If yes, please list the program and approximate date Student classification New Freshman (never attended college excluding courses taken while in high school) Transfer (previous or current attendance at another regionally accredited college or university) Returning to College of Nursing and Health Sciences after previous attendance Degree Previously Completed Degree Institution Completed High School Information List your high school information and request official transcripts to be sent directly to the Admissions Office. Current high school students should have a transcript sent now and another after graduation is noted on the transcript. All transcripts must be official and sent via mail or through an electronic transcript exchange. Faxed transcripts will not be accepted. ACT/SAT scores may be included with your high school transcript. Graduation Name of School City State Estimated GPA For those who have completed a high school equivalency exam, complete the following information. If we can access your transcript online, we will do so. If not, you will need to request an official transcript be sent directly to the Admissions Office. Graduation Name of Exam (GED, HiSet, etc.) State Website where we can access your results

3 Page 2 of 3 Postsecondary Education List every college, university, and vocational postsecondary school you have attended. Attach an additional page if needed. You must request official transcripts from every school to be sent directly to the Admissions Office. Students currently enrolled at another school should ask the school to send a transcript now and one after current courses are completed. All transcripts must be official and sent via mail or through an approved electronic transcript exchange. Faxed transcripts will not be accepted. Name of School City State Estimated GPA s Attended Name of School City State Estimated GPA s Attended Name of School City State Estimated GPA s Attended Civil or Academic Discipline Have you ever been suspended or dismissed from any school/college/university? Yes No Have you ever been placed on academic or disciplinary probation? Yes No Have you ever been convicted of a criminal offense? Yes No If you answered Yes to any of the above questions, please use another page to explain the reason or nature of the offense. Include information about suspended imposition of sentence and any offense that may appear on the criminal background check. Please list an address for every state where you have resided. A criminal background check will be performed. By signing this application you are authorizing Southeast Missouri Hospital College of Nursing and Health Sciences to complete this admission requirement. Address City State Zip s of residence Address City State Zip s of residence Address City State Zip s of residence Motivation Statement In the space below, state your personal and professional goals and how you expect your education will help you achieve these goals. I affirm that all information supplied is complete and accurate. I understand that any misrepresentation or change of facts could be cause for refusal of admission, cancellation of admission, or suspension from the College. I am aware that this application will not be considered until all required admission items are received by the College. Legal Signature It is the policy of Southeast Missouri Hospital College of Nursing and Health Sciences to maintain and promote equal education opportunity. Students and applicants will not be discriminated against on the basis of race, color, ethnicity, religion, national origin, gender, ancestry, marital status, sexual orientation, age, veteran status, or handicap which does not preclude the person from practicing the program profession after graduation and successful completion of the licensure, certification, or registry.

4 Page 3 of 3 First Name Middle Name Last/Family Name Previous Names (if applicable) This page of the application will not be provided to those who make the admission committee prior to the final decision. It is not used in the admission decision and will not be released except as group statistics for federal, state, and other reports. Questions regarding gender, race, and marriage status are important in determining the effectiveness of efforts related to the provision of equal education opportunity. Have you ever attend our Healthcare Camp while in high school? Yes No Birthdate: (mm/dd/yyyy) Circle one: Male Female Circle one: US Citizen Permanent Resident Alien (We are not authorized to admit other immigration classifications) Marital Status: Single Married Widowed Separated Divorced Number of dependents: Ethnicity: White/NonHispanic Hispanic/Latino Am. Indian/AK Native Pacific Island/Hawaiian Asian Black/African American Two or more ethnicities Unknown Other Employment Status: Fulltime Part time Not employed Will you continue working when enrolled? Yes No Military Status: Active Military Duty Military Veteran Never in the military For Office Use Only Application Fee Check or MO # Receipt # Seat Retainer Check or MO # Receipt # Revised 06/2017

5 Paramedic Work Experience Verification, has worked as a Paramedic (EMT-P) at Student name from to. Institution start date end date with hours (average) worked weekly. Supervisor Name/Title Supervisor Signature Address City State ZIP Phone Numbers cut here Paramedic Work Experience Verification, has worked as a Paramedic (EMT-P) at Student name from to. Institution start date end date with hours (average) worked weekly. Supervisor Name/Title Supervisor Signature Address City State ZIP Phone Numbers

6 Medical History Form Program: This information is confidential and will be used as an aid in providing necessary health care while you are a student. Please return this form with your application. Health information is only reviewed after the admission committee recommends an applicant be admitted. First Name Middle Name Last/Family Name Previous Names (if applicable) Circle one: Male Female Social Security Number of Birth (mm/dd/yyyy) Address City State Zip County Home Phone Cell Phone Work Phone address Emergency Contact: Full Name Relationship _ Address City State Zip County Home Phone Cell Phone Work Phone Family Physician: Full Name Phone Number _ Address City State Zip County Insurance: Medical Insurance Company Policy Number Group Number The College strongly urges every student to subscribe to an insurance plan which provides comprehensive medical, surgical treatment, and accidental care. Immunization History: The Missouri Division of Health is requesting we have a documented record of a student s immunizations. Please include a copy of your immunization records: from your baby book, public health record, high school records, or a copy of your doctor s records. These include measles, mumps, and rubella (MMR), chicken pox, hepatitis B, and tdap (tetanus/pertussis). Personal Health History: Please indicate which diseases or problems you currently have or have had in the past and explain yes answers on the lines below. Childhood Diseases Measles (Regular, Hard, Red) Yes No Rubella (3 day) Yes No Chicken Pox Yes No Mumps Yes No Acute Diseases Hepatitis A Yes No Infectious MoNonucleosis Yes No Pleurisy Yes No Pneumonia Yes No Poliomyelitis Yes No Repeated bouts of Strep Throat Yes No Other (list below) Yes No Chronic or Continuing Problems Anemia Yes No Anxiety Yes No Arthritis Yes No Asthma Yes No Chronic Back Problem Yes No Cancer Yes No Chronic Cough Yes No Colitis/Colon Problems Yes No Convulsions or Seizures Yes No Depression Yes No Diabetes Yes No Diminished Hearing Yes No Dizziness/Fainting Yes No Excessive Drinking or Drug Use Yes No Headaches Yes No Please explain all Yes answers, any surgeries, allergies, and any serious injuries (broken bones, etc.): Heart Disease Yes No Congenital Heart Problems Yes No Hemophilia Yes No Hepatitis B Yes No Hepatitis C Yes No High Blood Pressure Yes No Frequent Indigestion Yes No Kidney/Bladder Problems Yes No Malaria Yes No Mental Disorders Yes No Sinusitis Yes No Tuberculosis Yes No Drug Allergies Yes No Other Allergies Yes No Other (explain below) Yes No Current Medications: I do hereby consent, authorize, and request health services personnel and any physician or medical representative to whom referral is made to conduct treatment which may deem advisable in the event should I require medical care while a student at Southeast Missouri Hospital College of Nursing and Health Sciences. Legal Signature

7 Exhibit B AUTHORIZATION FORM 4/6/2016 Southeast Missouri Hospital College of Nursing & Health Sciences 2001 William St., Cape Girardeau, MO Phone: 573/ Fax: 573/ First Name Middle Name Last Name Alias/Maiden Name(s) Will Employee's Salary Exceed $75,000? No Yes Social Security Number of Birth Race Gender Male Female Mailing Address (NO P.O. Boxes) City State Zip As part of the employment volunteer student credentialing process, I consent to the release of my criminal background records and motor vehicle driving records or any search listed below by any and all states or agencies holding such records. I also agree to an investigation and the obtaining of a consumer report solely for employment volunteer student credentialing purposes. By signing this consent, I acknowledge I have received in writing a Disclosure Regarding Procurement of a Consumer Report. I understand that the Company named above may use this consent on multiple occasions to request such consumer reports. This consent will remain effective until I have affirmatively revoked it. Signature of Applicant BACKGROUND SEARCHES OIG (Medicare/Medicaid Fraud & Abuse) GSA (Federal Procurement Fraud) **FCSR SSN Plus (Address & Alias Name are included) Address Verification Alias Name Search DATE: / / Government Watch List (includes DOC Entity List & Denied Persons List, DOT Specially Designated Nationals & Blocked Persons List, DOS Proliferation List & more) Wants & Warrants (Nationwide - extraditable only) OFAC (Specially Designated Nationals and Blocked Persons List) Child Abuse/Neglect IL** IA** IN** KS** MO* NE** TN *MO Mental Health Employee Disqualification Registry MO EDL (Employee Disqualification List) FEDERAL COURTS - Criminal State 1: 2: SEX OFFENDER Nationwide or State 1: DRIVING RECORD State DL# PROFESSIONAL LICENSE National or State Type: License Number: EDUCATION School Name (include campus): City/State: / Major: Graduation : / Degree Type: (BSN, B.A., etc.) Name While Attending: If additional Verifications are needed, refer to application during data entry or document on another Background Check Request Form. EMPLOYMENT Company: City/State: / Phone: / - Manager: Start : / End : / Title: Starting Wage:$ Ending Wage:$ Duties: Reason for Leaving: If additional Verifications are needed, refer to application during data entry or document on another Background Check Request Form. LIST CITY/COUNTY CRIMINAL SEARCHES NEEDED States with county by county access only: CA, LA, MA, WV and WY County 1: State: County 2: State: County 3: State: STATEWIDE CRIMINAL - A Statewide/State Repository houses records from all jurisdictions throughout the State AL* AK AZ AR* CO CT* DE DC* FL GA* HI ID** IN IA* KS KY ME MD MI MN MO MS* MT NE NV* NH** NJ NM* NY* NC ND OH* OK OR* PA RI* SC SD TN TX UT* VA* VT* WA WI Note: Nevada & Ohio are Felony Only Illinois Healthcare-compliance with IL Healthcare Worker Background Check Act (IL Police Full-State Repository Criminal) MO-includes MO Sex Offender results at no additional cost (MO State Highway Patrol Full-State Repository Criminal search) *Required Form(s) & **Required Special Form(s) must be ATTACHED when ordering or faxed to