APPLICATION FOR REGISTERED NURSING PROGRAM FALL 2017 (Filing deadline: February 10, 2017, 4:00 PM) PLEASE TYPE OR PRINT NEATLY

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1 APPLICATION FOR REGISTERED NURSING PROGRAM FALL 2017 (Filing deadline: February 10, 2017, 4:00 PM) PLEASE TYPE OR PRINT NEATLY NOTE: N student may enrll in the Nursing Prgram unless he/she is admitted t City Cllege f San Francisc. Cmpletin f this frm is nt a substitute fr cmpletin f the CCSF applicatin. CCSF admissin frms are available at Office f Admissins and Recrds, Rm E107, Ph: (415) r yu may visit the website at 1. Name LAST FIRST MIDDLE DATE OF BIRTH If yu have used ther name(s) n fficial transcripts, list them belw. Ethnic Backgrund** Male** Female** **ptinal/vluntary and des nt affect enrllment. Infrmatin will be used fr statistical purpses Mandatry respnses are required fr questins 2 t 11, if nt applicable, write N/A in the sectin. 2. CCSF Student I.D. # Scial Security # 3. Check nly ONE categry that applies t yu: Regular Enrllment Military Advanced Placement* BRN Make Up* Advanced Placement (LVN Only)* Transfer frm anther nursing prgram* 30 Unit Optin (LVN nly)* (* see Nursing Infrmatin Handut fr descriptin f abve categries) 4. LVN Only Advanced Placement and 30 Unit Optin must prduce valid Califrnia LVN license. Please prvide the riginal license t the Department fr verificatin. Fr Office Use Only: LVN License # Expiratin Date 5. Mailing Address _ NUMBER & STREET CITY STATE ZIP CODE 6. Phne Numbers HOME CELL WORK 7. E mail ; PLEASE PRINT CLEARLY CCSF if assigned

2 8. Persns t be cntacted in case f emergency a. Name Phne Address City State Zip Cde b. Name Phne Address City State Zip Cde 9. Please check the fllwing: a. I have I have nt attended CCSF RN Prgram r anther Registered Nursing Prgram. If yu have attended anther prgram, what prgram(s)? Please list all Nursing Prgram(s) previusly attended, including CCSF RN Prgram: NAME OF RN PROGRAM YEARS ATTENDED REASON FOR LEAVING Please be aware that any failure frm anther RN Prgram r CCSF RN Prgram, disqualifies yu fr admissin. In rder fr ur Department t cnsider yur applicatin, yu must submit a letter n fficial schl statinery frm the Directr f the Nursing Department at the cllege in which yu were enrlled. It must address the fllwing: Length f the time yu were enrlled. Must state that yu were in gd standing at the time f withdrawal frm their Nursing Prgram, with n histry f failing any curse, including clinical. Must have statement that demnstrates that yu were nt failing any f the curses yu were enrlled in at the time f withdrawal. City Cllege f San Francisc Registered Nursing Department Nursing Prgram Applicatin Fall

3 10. List in chrnlgical rder all clleges and universities previusly attended, including CCSF. Applicant must prvide fficial transcripts in a sealed envelpe fr each cllege and university listed. (Cntinue n a separate sheet if necessary) Name f Cllege/University City, State Years Attended Units Cmpleted Degree/Certificate 11. Prgram Prerequisites: Curses Anatmy 25 General Human Anatmy Physilgy 1 r 12 Intr t Human Physilgy Institutin Where Curses were Taken Curse Name & Number Semester & Year Cmpleted Grade Micrbilgy 12 Intr t Micrbilgy English 1A*** University Read & Cmpsitin CCSF Math 40*** (Elementary Algebra) r Placed int Math 60 r higher Please attach a cpy f yur CCSF Math test scres. ***Imprtant: Students wh cmpleted English and Math curses at anther cllege/university must bring their transcript and a curse descriptin frm that cllege t the CCSF Matriculatin Office, Cnlan Hall Rm 204 t btain a waiver fr placement testing fr thse curse(s). If yu are using a test scre t waive placement testing, please prvide a cpy f yur test scres. Attach a cpy f the waiver cmpleted by the City Cllege f San Francisc Matriculatin Department t this applicatin fr the Nursing Prgram. N In Prgress Curses are cnsidered fr meeting curse prerequisites. City Cllege f San Francisc Registered Nursing Department Nursing Prgram Applicatin Fall

4 Students will be cnditinally admitted t the R.N. Nursing Prgram. These students will be required t submit t a backgrund screening check, health + immunizatin reprt, current CPR fr healthcare prviders, and must submit ATI TEAS Test (TEAS f Essential Academic Skills) first attempt scre. TRANSCRIPT INFORMATION The Nursing Department must verify that yu have satisfied all curse prerequisites in rder t determine if yu are eligible fr enrllment. Official transcript(s) in a sealed envelpe must be submitted with this enrllment frm including CCSF transcripts. Please nte that CCSF Transcripts Department des nt prvide same day service. Yu must request yur CCSF transcript in advance t meet the RN Prgram deadlines. Yu may submit yur cmpleted nursing applicatin packet in persn in the drp bx lcated inside the Registered Nursing Office Rm C340, Clud Hall Bldg., Ocean Campus r Mail t: City Cllege f San Francisc Registered Nursing Department Attn: Nursing Applicatin 50 Phelan Avenue Mailbx C40 San Francisc, CA Clsing date fr applicatins and specific supprting materials must be received in a 9 x 12 manila envelpe by 4:00 pm, February 10, Pstmark nt accepted! Nte: An applicatin will nt be cnsidered cmplete unless all requested infrmatin is filled in and materials listed have been received by 4:00 P.M. n the clsing date f enrllment frm. Incmplete file r failure t submit fficial transcripts frm any cllege may subject the applicant t disqualificatin frm the applicatin prcess. Enrllment in the RN Prgram is pen t all. Please nte the fllwing fr yur infrmatin: The licensing prcess fr becming a registered nurse in Califrnia is under the jurisdictin f the BRN (Bard f Registered Nursing). The BRN requires disclsure f all misdemeanr and felny cnvictins fr all license applicants and disclsure f all disciplinary actins taken against a license applicant wh already has a practical nurse, vcatinal nurse r ther prfessinal license. Fingerprinting is als required fr criminal backgrund check. NOTE: We reserve the right t verify all infrmatin prvided by the student. By submitting this enrllment frm and as indicated by my signature belw, I certify that if any f the infrmatin I have prvided is nt cmplete and truthful, my enrllment may be canceled and I may be subject t discipline, up t and including ptential expulsin frm the San Francisc Cmmunity Cllege District. Applicant Signature (Required) Date City Cllege f San Francisc Registered Nursing Department Nursing Prgram Applicatin Fall

5 Please keep this page fr yur wn reference. Enrllment in the RN Prgram is pen t all. Please nte the fllwing fr yu infrmatin: The licensing prcess fr becming a registered nurse in Califrnia is under the jurisdictin f the BRN (Bard f Registered Nursing). The BRN requires disclsure f all misdemeanr and felny cnvictins fr all license applicants and disclsure f all disciplinary actins taken against a license applicant wh already has a practical nurse, vcatinal nurse r ther prfessinal license. Fingerprinting is als required fr criminal backgrund check. Beginning Nvember 1, 2012, CCSFmail will be the fficial used fr all enrlled students. All fficial CCSF cmmunicatins will be sent t this accunt and nt t any ther accunts. Student All City Cllege credit students are issued a CCSF Gmail address, prvided by GOOGLE. All fficial CCSF will be sent t the CCSF Gmail address. By using the Gmail address, CCSF can ensure that students receive registratin, financial aid and ther imprtant infrmatin. Students have the ptin t frward CCSF Gmail messages t an accunt which they check regularly. Students can find infrmatin abut their CCSF Gmail address and passwrd by: 1. Lgging n t Web4 2. Clicking n the Persnal Infrmatin tab. 3. Scrlling dwn Additinal infrmatin may be btained by phne frm Gmail Help Desk at , by at mailhelp@mail.ccsf.edu, r frm the CCSF Gmail FAQ website at The FAQ website has details fr lgging n and frwarding t a different address. Make sure yu submit everything yu need t apply: Cmpleted cllege applicatin fr admissin r readmissin at the Registrar s Office ( in rder t btain a CCSF student ID number. This ID number must als be written in the Nursing Applicatin. Cmpleted Nursing Applicatin Math and English Placement Testing Waiver Test waivers fr English and Algebra are nly fr nursing applicants wh have satisfied CCSF placement test requirements thrugh external surces such as ther cllege attended r (SAT, AP) scres. Bring prf (test scre r transcripts) t the Matriculatin Office, Cnlan Hall, Rm 204 t btain the waiver. This waiver must accmpany yur Nursing applicatin. All fficial transcripts including CCSF are required in a sealed envelpe fr each Cllege/University listed. Include all dcuments listed in a 9 x 12 manila envelpe, mail r walk in t: CCSF, Nursing Dept. Attn: Nursing Applicatin, 50 Phelan Avenue Mailbx C40, SF CA Submissin Deadline fr Fall 2017 applicatins: Friday, February 10, :00 P.M. Yur cmpleted applicatin and all supprting materials must be received in the CCSF Registered Nursing Office NO LATER THAN 4:00 P.M.! Pstmarks will nt be accepted. Late r incmplete applicatins will nt be prcessed. City Cllege f San Francisc Registered Nursing Department Nursing Prgram Applicatin Fall