ADMISSION INFORMATION

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1 ADMISSION INFORMATION Lake-Sumter State College Nursing Program is a limited access program. Students must meet certain criteria before applications forward to the Nursing Selection Committee for admission consideration. Consult the Nursing Information Packet located on the web at for complete details regarding Admission Requirements, Application Procedure, Selection Criteria, and Selection Process. Applicants who did not attend a mandatory program information session prior to application return deadline will not forward to program admission selection committee. APPLICATION RETURN DEADLINES BRIDGE March 1, 2018 GENERAL March 1, 2018 APPLICATION RETURN PROCEDURE Submit original Application Form (pages 1-3) plus Attachments applicable to you by mail or in person. Applications must be physically received in the nursing offices on Leesburg or South Lake campuses by the end of the business day of the application return deadline. Post mark dates are not considered receive dates. CONTACT INFORMATION LEESBURG SOUTH LAKE Nursing Main Phone Nursing Website Nursing Address lnursinginfo@lssc.edu slnursinginfo@lssc.edu

2 APPLICATION ATTACHMENTS CHECKLIST Only complete applications forward to program admission selection committee. Only attachments listed below are accepted with the application. All unrequested material is destroyed. Make copies required for submission and/or for your records prior to surrendering application. ALL applicants: Proof of Residency: Attach copy of FL Driver s License or Vehicle Registration (in your name). Education Verification: High School Health Occupations curriculum- If checking YES box, submit documentation to Baccalaureate and Workforce Suite- Student Services Building- Room 151, Leesburg Campus by application return deadline. Grade Amnesty: Attach copy of request (if applicable). Course Substitution(s): Attach copy of request(s) (if applicable). LPN-BRIDGE applicants only: License: Attach 2 copies of current Florida LPN License. (2 pages. Do not combine License and Residency Proof on same page.) PARAMEDIC-BRIDGE applicants only: Certification: Attach 2 copies of current Florida Paramedic Certification. (2 pages. Do not combine Certification and Residency Proof on same page.) DIRECTIONS FOR COMPLETION Complete sections 1-4 and 5a or 5b (according to track/option selection) of the application (pages 1-3). Complete all applicable sections even if coursework completed at LSSC. For section 5a or 5b: o Write course sub in Term/Year column for courses you submitted course substitution forms. For section 5a only: o If currently enrolled in courses at non- LSSC institution fill in space provided for Spring Semester End Date. o Write in progress in Term/Year column for courses in progress this spring semester. Double check: 1) all blanks completed 2) all attachments per the ATTACHMENTS CHECKLIST.

3 Nursing Staff Use Only: (Students- DO NOT Complete.) Reconcile Database to Application//File Updates Reviewer Reviewer TRACK LAST NAME FIRST NAME MIDDLE INITIAL LOG NAME CHANGES INFO SHEETS MOVED HESIs MOVED DATE OF BIRTH COUNTY OOC MAILING ADDRESS RESIDENT ADDRESS EMPLOYMENT JOB TITLE WORK PHONE HOME PHONE CELL PHONE GENDER STATUS TO APP LSSC NURSING PROGRAM ADMISSION APPLICATION 2018 Lake-Sumter State College is committed to non-discrimination based on race, color, sex, ethnicity, gender, national origin, age, disability, genetic information, marital status, veteran status, religion, sexual orientation, political affiliation and pregnancy. This commitment applies in all areas to applicants, visitors, students, faculty, administrators, staff, and others affiliated with the College. 1. COVER INFORMATION APPLICANT NAME (print) PROGRAM TRACK/(Option) LAST: FIRST: XID #: GENERAL (Preferred) GENERAL (Compressed) LPN-BRIDGE PARAMEDIC-BRIDGE Please accept my application for admission to the Associate Degree Nursing Program. I understand in order to be considered for admission I must meet all requirements and furnish all necessary documentation. I attest all information presented in this application is accurate and true and verify I physically reside in the County of Residence indicated. Signature: Date: 1

4 LSSC NURSING DEPARTMENT ADMISSION APPLICATION CONTACT INFORMATION (type or print legibly) LAST NAME FIRST NAME MIDDLE INITIAL M GENDER (select one) XID NUMBER DATE OF BIRTH COUNTY OF RESIDENCE F MAILING ADDRESS CITY STATE ZIP STREET ADDRESS (if different than mailing address) CITY STATE ZIP PLACE OF EMPLOYMENT JOB TITLE WORK PHONE (include area code) HOME PHONE (include area code) CELL PHONE (include area code) LAKEHAWK ADDRESS (provide personal address only if not LSSC student) 3. EDUCATIONAL BACKGROUND All Applicants High School Health Occupations Curriculum? BRIDGE Track Students Only LPN or PARAMEDIC School Attended: Yes No (If yes, submit documentation to Baccalaureate/Work Force Suite- SSB 151 (Leesburg Campus by appl n return deadline.) (On separate pages-- Attach 2 copies of current Florida LPN license or PARAMEDIC certification.) 4. CRIMINAL BACKGROUND ACKNOWLEDGEMENT I acknowledge content of criminal background history is a factor of eligibility for seating/continuing enrollment in the nursing program and FL RN licensure. I reviewed information provided by FL BON at above web link for Applicants with Criminal History and Health Care Fraud; Disqualification for License, Certificate, or Registration. If applicable, I reviewed FL State Statutes relating to contents of my criminal background history. I understand laws and rules change over time; those in effect at time of NCLEX application determine my eligibility for licensure in regard to my criminal background history. LAST: FIRST: XID #: Signature Date 2

5 LSSC NURSING DEPARTMENT ADMISSION APPLICATION 2018 LAST: FIRST: XID #: GENERAL (Preferred) and BRIDGE APPLICANTS ONLY 5a. ACADEMIC COURSE COMPLETION** Spring Semester End Date (if enrolled elsewhere than LSSC) Course Term/Year Institution Anatomy & Physiology I w/lab (BSC 2093 & BSC 2093L) Anatomy & Physiology II w/lab (BSC 2094 & BSC 2094L) Microbiology w/lab (MCB 2010 & MCB 2010L) English Composition I (ENC 1101) Humanities Elective Nutrition w/diet Therapy (HUN 1201) [or General/Intro Nutrition Course] Introduction to Psychology (PSY 2012) Psychology of Human Development (DEP 2004) Math for Health Related Professionals (MTB 1370) Math Proficiency (MAT 0027/0028) [check one for attained by: Exempt Status Test Score Course ] if course, fill in next line Specify Course Computer Proficiency: (CGS 1100) [check one for attained by: Test Score Course ] if course, fill in next line Specify Course **Do not leave any courses blank. Courses in progress, write in progress in Term/Year column. Course Substitution Submitted, write course sub in Term/Year column. GENERAL (Compressed) APPLICANTS ONLY 5b. ACADEMIC COURSE COMPLETION (Courses Must Be Complete Prior to Application) Course Term/Year Institution Anatomy & Physiology I w/lab (BSC 2093 & BSC 2093L) English Composition I (ENC 1101) Nutrition w/diet Therapy (HUN 1201) [or General/Intro Nutrition Course] Introduction to Psychology (PSY 2012) Math for Health Related Professions (MTB 1370) Math Proficiency (MAT 0027/0028) [check one for attained by: Exempt Status Test Score Course ] if course, fill in next line Specify Course 3

Attachment: Program Application- Spring 2018 PLANNING TO GO ON FOR YOUR BSN? LSSC IS THE PLACE In 2017 Lake-Sumter State College received approval* to offer an RN-BSN program.

6 Attachment: Program Application- Spring 2018 PLANNING TO GO ON FOR YOUR BSN? LSSC IS THE PLACE In 2017 Lake-Sumter State College received approval* to offer an RN-BSN program. Preparations are underway to begin admission and enrollment. If you are planning to complete your BSN after graduation from LSSC nursing program please complete this form and return with your ADN application. Last Name: First Name: XID: Yes, I am interested in obtaining my BSN after completion of ADN. I already spoke with someone about LSSC RN-BSN program. YES NO Please contact me with information about the LSSC RN-BSN program. YES NO LSSC Contact Information for RN-BSN Program: Shirley Bazemore or bazemors@lssc.edu * State of FL Approval complete. Pending SACSCOC approval.

LSSC Nursing Program. Admissions Information Packet FOR CLASSES STARTING. Summer 2018 and Fall 2018

LSSC Nursing Program. Admissions Information Packet FOR CLASSES STARTING. Summer 2018 and Fall 2018 LSSC Nursing Program Admissions Information Packet FOR CLASSES STARTING Summer 2018 and Fall 2018 Introduction o Accreditation o Seating Preference o Program Tracks o First Required Actions Preparing for