FOUR RIVERS REGIONAL PRACTICAL NURSING PROGRAM APPLICATION FORM

Transcription

1 FOUR RIVERS REGIONAL PRACTICAL NURSING PROGRAM APPLICATION FORM Name: Address: 340 Washington Street 127 Industrial Drive 1600 Hwy 51 South Newbern, TN Ripley, TN Covington, TN PERSONAL DATA Street or P.O. Box City State Zip Phone: Home Work NAME OF ENTRANCE EXAM: Reading Score: Math Score: Date of Exam: Test Site: Educational Background (check one): High School Diploma GED Citizenship Status (check one): U.S. Citizen Foreign Permanent Citizen Foreign Temporary or Student Visa Employment: List present and past employment, beginning with the most recent. Employment Employer and Job Reason for Dates Supervisor's Name Title Leaving

2 Character References: List three people you plan to ask for a work reference. These references need to be from those who have had supervision over you. Persons with no work history may provide character references from instructors, community leaders, and charity organizations ONLY if you have NEVER worked. (Relatives, Pastors and Friends are NOT acceptable). Name Address Phone Years Known Relationship Whether while a juvenile or an adult, have you EVER been convicted of a crime or been expunged from a crime other than minor traffic violations? (DUIs are not minor traffic violations) Yes No If so, please explain: *An affirmative response is not necessarily a bar from admission. Factors such as age at the time of conviction, elapsed time from the date of conviction, seriousness and nature of the offense, and rehabilitation will be taken into account. *Students with an affirmative answer to the above question, may, upon graduation from the program, be ineligible for licensure and are advised to consult with the Tennessee Board of Nursing regarding their licensure eligibility. * Any intentional misrepresentation of any of the information contained above may result in refusal of your application or suspension from the TENNESSEE COLLEGE OF APPLIED TECHNOLOGY should you be admitted. *Attached is a list of the technical standards required of a Licensed Practical Nurse. Please read this description carefully at this time. The requirements reflect typical duties and conditional acceptance will be made contingent upon you, the applicant, providing information that he or she can perform the technical requirements with or without reasonable accommodation. A portion of your clinical experiences may be on the evening and night shifts. Will this present

3 a problem for you? Yes No If yes, please explain. 2 of 4 The Admissions Committee would like to get to know you as well as possible through this application. With this goal in mind, describe your reasons for choosing nursing as a career. Please provide any additional information about yourself or your qualifications which you may wish to share with us. (Please do not exceed words.)

4 3 of 4 STATEMENTS OF UNDERSTANDING AND AGREEMENT: I certify that the information given in this application is correct and complete to the best of my knowledge. I hereby authorize the TENNESSEE COLLEGE OF APPLIED TECHNOLOGY to make all necessary investigations concerning me or my actions and to receive my academic records or other materials pertinent to my qualification. I further authorize and request each former employer, educational institution, or organization (including law enforcement agencies) to provide all information that may be sought in connection with this application. I understand that any intentional misrepresentation of any of the information contained in this application may result in refusal of my application or in suspension from the TENNESSEE COLLEGE OF APPLIED TECHNOLOGY should I be admitted. Date Signature The Tennessee College of Applied Technology offers equal opportunity for admission to all qualified persons without regard to race, color, religion, sex, handicap, or national origin. In accordance with the privacy Act of 1974, applicants and enrolled students are advised that the requested disclosure of their Social Security numbers to the Office of Admissions is voluntary. Students who do not provide TCAT with their Social Security numbers will be assigned special nine-digit numbers. This number or the Social Security number will be used: (a) to identify such student records as applications for

5 admission, registration and course enrollment documents, grade reports, transcript requests, certification requests, and permanent academic records and (b) to determine eligibility, certify school attendance, and report student status. Students are notified, however, that only the Social Security number may be used as an identifier for grants, loans and other financial aid programs according to federal regulation. The student's Social Security number will not be disclosed to individuals or agencies outside TCAT except in accordance with the institutional policy on student records. 4 of 4 FOUR RIVERS REGIONAL PRACTICAL NURSING PROGRAM Technical Requirement for LPN PHYSICAL DEMAND=CONTINUOUSLY Verbal Communication Written Communication Hearing Ordinary Conversation Seeing Hear/Far with acuity Chemical Exposure to Chemotherapeutic Agents General Occupational Exposure to Airborne Particulate Exposure to Blood and Body fluid Exposure > 1 per month Exposure to infection PHYSICAL DEMAND=FREQUENTLY Bend/Stoop Squat/Crouch Overhead: Reach > 7# Push/Pull > 7# Lift > 7# Carry up to 10 lbs. Patient transfers Push/pull up to 10 lbs. Patient bed activities Distinguishing colors Repetitive Motion (Hands/Wrists) Marked changes in Temperature and Humidity PHYSICAL DEMAND=OCCASIONALLY

6 Crawl, Balance/Ladder Carry up to 24 lbs. Lift up to 24 lbs. Push/pull up to and > 75 lbs. Work with moving machinery, Radioactivity, and excessive noise Revised bb