Office Use Only Date Submitted to Nursing Office SOUTHWESTERN MICHIGAN COLLEGE NURSING PROGRAM Application to Begin the Nursing Program Complete and return to the Nursing Department Electronic signatures are not accepted NAME Student ID# (Last) (First) LOCAL ADDRESS (Street) (City) (State) (Zip) PHONE: Home ( ) Work ( ) SMC EMAIL: @swmich.edu NON-SMC EMAIL: For which program are you applying for? (Check one) A.D.N. (Registered Nursing) L.P.N.-A.D.N. (Registered Nursing for LPNs) Please check pre-requisites completed and grade earned. Include courses in progress. (If transferred, use a T ). A.D.N. Pre-Requisites L.P.N.-A.D.N. Pre-Requisites Course Grade Semester Taken Course Grade Semester Taken BIOL 214 BIOL 214 CHEM 100 ENGL 103 ENGL 103 HEED 107 MATH 101 *NOTE: There is a 5 year limit on BIOL 215 (this course is required for program completion) Which Semester do you wish to begin Nursing? 1 st Choice Spring (Jan) Fall (Sept) (Year) (Year) 2nd Choice Spring (Jan) Fall (Sept) (Year) (Year) **NOTE: Prerequisites may only be repeated once to be considered for admittance to the nursing program Signature Date Over
Please check the forms you have already submitted to the NURSING Office. FORM Applicant Information Page (Page 1) Health Records (Applicant & Physician) Immunization Records (or proof of immunity) Rubella Rubeola (need proof of two) TdaP (tetanus: within last 10 years) TB (Mantoux - 1yr; Skin or Blood test; Chest X-rays are no longer accepted) Hepatitis B (three shots in the series) Chicken Pox Verification Form (or proof of immunity) High School Transcript/GED College Transcripts (if applicable) 1. 2. 3. 4. Copy of Drivers License Proof of Citizenship (birth certificate, permanent resident card or current I-20) If LPN to RN Copy of current LPN License COMMENTS: T:\DEAN OF NURSING\Nursing\Application SON\SON_Application_01282016.Doc Revised 11/07; 02/19/08; 11/07/02; 03/22/04; 08/06/07; 07/08 (web), 02/19/09; 03/26/10; 01/27/11; 02/28/12; 02/03/15; 09/24/2015; 1/28/2016; 10/4/2016; 11/28/2016
SOUTHWESTERN MICHIGAN COLLEGE SCHOOL OF NURSING 58900 CHERRY GROVE ROAD-DOWAGIAC, MI 49047 HEALTH RECORD/PHYSICIAN'S FORM TO THE PHYSICIAN: The applicant has been asked to complete the history on the attached copy. Please review for accuracy. Using the following form please make the necessary examinations. This information will be used in the best interest of the applicant and patient safety. This applicant is being considered for a health occupation; therefore, we are concerned about physical stamina. Applicant's Name Ht Wt BP P R T Check each item: Normal Abnormal Nature of Abnormality Skin Head/Neck/Thyroid Eyes/Vision Ears/Hearing Nose/Sinuses/Mouth Throat/Nodes Chest/Breasts Lungs Heart Abdomen Extremities/Joints Vascular Neuro/Reflexes Mental Status IMMUNIZATION OR PROOF OF IMMUNITY (Must be up to date with immunization record included) Month/Day/Year TB test or CXR Neg Pos (Mantoux only) Must be done yearly (skin or blood test only): CXR ARE NOT Accepted Tdap (Tetanus) Within ten years Rubella Lab evidence or vaccine Rubeola Lab evidence or two vaccines if born after 1957 1 st 2 nd Hepatitis B Series Initiated Chicken Pox (Varicella) Proof of disease or immunity Is this applicant subject to any physical limitations? No Yes Explain, if yes Additional comments regarding the applicant s physical and/or mental health? Physician's Signature Date Address T:\DEAN OF NURSING\Nursing\Application SON\Health Record_Physician.Doc Rev.10/8/97 8/00; 1/27/10; 2/14/13; 1/26/2016; 10/4/2016
SOUTHWESTERN MICHIGAN COLLEGE SCHOOL OF NURSING 58900 CHERRY GROVE ROAD-DOWAGIAC, MI 49047 HEALTH RECORD/APPLICANT S FORM INSTRUCTIONS TO THE APPLICANT: This form must be completed, signed and returned to The Nursing Office. All information is confidential and should be as complete as possible. This information will be used in the best interest of the applicant and patient safety. Please PRINT IN INK or TYPE. You should complete this form. Your physician should complete the other form. Please make sure that you and your physician sign in the proper places. PART ONE TO BE COMPLETED BY THE APPLICANT DATE Name Sex M F DOB (Last) (First) Street Student ID # City State ZIP Current Phone number (hm) (wk) Current Medications Current conditions under MD s Care Sensitivities or Allergies Physical Impairments Do you have a lifting weight restriction-if yes, please explain HISTORY Have you had: (check each item) YES NO If yes, explain Tuberculosis Diabetes Epilepsy Cancer Asthma Heart Disease High Blood Pressure Eye or Ear Problems Shortness of Breath Kidney Disease Over Revised Feb 2009
YES NO If yes, explain Fainting or Dizzy Spells Color Blindness Contact Lenses Learning Disabilities Severe Headaches Anxiety Reactions PRINT name of physician who will perform your examination: Name Street City State ZIP Phone To the best of my knowledge, the above information is correct. I understand that misinformation may result in dismissal. Applicant s Signature Date Revised Feb 2009
Southwestern Michigan College 58900 Cherry Grove Road Dowagiac, Michigan 49047 Phone: 269-782-1236 Fax: 269-782-1239 CRIMINAL RECORD CHECK CONSENT FORM As a health careers student at Southwestern Michigan College, I understand that it is the policy of the institution to secure criminal conviction history information as port of the screening process for students using the information provided below. List all states that you have worked or lived in for the past seven years. NOTE: A copy of your current driver s license must be submitted with this form. NAME Last First Middle ADDRESS: PREVIOUS ADDRESS (if less than 7 years): Street City State Zip Code OTHER STATES: MAIDEN NAME/NAMES PREVIOUSLY USED: BIRTHDATE: RACE: SEX: SOCIAL SECURITY NUMBER: DRIVER S LICENSE NUMBER: State Issuing Number I understand that the Central Records Division of the Michigan State Police, Lansing, Michigan, requires the above information. I authorize Southwestern Michigan College to utilize the above information for the purpose of obtaining a conviction only crime file search. I understand that if it is discovered that I have a criminal record, it will prohibit my admission to a health careers program. Applicant s Signature Revised 4/25/11 Date
SOUTHWESTERN MICHIGAN COLLEGE SCHOOL OF NURSING & HEALTH SERVICES CHICKEN POX VERIFICATION FORM (Varicella Zoster) I, declare that I have had the disease of chicken pox. Print Name Date: Student Signature
SOUTHWESTERN MICHIGAN COLLEGE SCHOOL OF NURSING & HEALTH SERVICES ANTIBODY STATUS PROFILE A five-titer test, the Antibody Status Profile, is being done in conjunction with Lee Memorial Hospital in cooperation with the Michigan Department of Public Health. This lab test covers titer levers for: measles (rubeola,), mumps, rubella, varicella zoster (chicken pox), and Hepatitis B. Any nursing or allied health student needing the five titer test can utilize the following procedure. No appointments are necessary but the individual may wait depending on current situations in the laboratory. Walk-ins are processed on a first come, first serve basis. PROCEDURE 1. Go directly to Patient Registration at Lee Memorial Hospital (Dowagiac). 2. Identify yourself as a SMC nursing or allied health student. Ask for the ANTIBODY STATUS PROFILE. Complete the appropriate forms. 3. Pay $36 in cash. Students receiving funding from Michigan Works must first obtain an approved check. If this check is not available, the student must pay. Payment is in cash, correct change is preferred. 4. You will receive a paper to take to the Laboratory secretary. The sample will then be obtained. The sample and forms will be sent to the Michigan Department of Public Health by Lee Memorial Hospital for processing. 5. The lab results will be sent to the individual (student) listed on the top of the form. Students are to provide the School of Nursing & Human Services with a copy (not the original) of the results. STUDENTS: Lee Memorial Hospital is providing the college with the opportunity to reduce the cost of entering school. Please avoid early morning hours when they are very busy. If they cannot provide services because of patient load, please comply with their request to return at a more appropriate time. Thank you. Borgess-Lee Hospital 420 High Street Dowagiac, Michigan 49047 269-782-8681 Laboratory Hours: 8:00 a.m. 4:30 p.m., Monday through Friday. NOTE: Lab hours and prices are subject to change without notice. T:\DeanofNursing\Staff\Nursing\Antibody Status Profile.doc
SOUTHWESTERN MICHIGAN COLLEGE SCHOOL OF NURSING & HEALTH SERVICES ESTIMATED COST SHEET RN PROGRAM 2016-2017 ACADEMIC YEAR APPROXIMATE COST In-District In-State Out-State Semester ONE - Prerequisites 17 Contact Hours Tuition & Fees $ 2,771.00 $ 3,366.00 $ 3,599.75 Textbooks $ 1,100.00 $ 1,100.00 $ 1,100.00 TOTAL $ 3,871.00 $ 4,366.00 $ 4,699.75 Semester TWO Nursing Semester I 27 Contact Hours Tuition & Fees $ 4401.00 $ 5,346.00 $ 5,717.25 Textbooks (required) $ 1026.00 $ 1026.00 $ 1026.00 Uniform $ 150.00 $ 150.00 $ 150.00 Shoes $ 75.00 $ 75.00 $ 75.00 Name Badge $ 4.00 $ 4.00 $ 4.00 Stethoscope $ 15.00 $ 15.00 $ 15.00 Scissors $ 4.00 $ 4.00 $ 4.00 Watch with second hand $ 50.00 $ 50.00 $ 50.00 CPR $ 55.00 $ 55.00 $ 55.00 Malpractice Insurance $ 13.00 $ 13.00 $ 13.00 Kaplan Access $ 144.00 $ 144.00 $ 144.00 SEMESTER TOTAL $ 5,937.00 $ 6,882.00 $ 7,253.25 Semester THREE Nursing Semester II 19.5 Contact Hours Tuition & Fees $ 3,178.50 $ 3,861.00 $ 4,129.25 Textbooks (required) $ 350.00 $ 350.00 $ 350.00 Malpractice Insurance $ 13.00 $ 13.00 $ 13.00 Kaplan Access $ 144.00 $ 144.00 $ 144.00 SEMESTER TOTAL $ 3,685.50 $ 4,269.00 $ 4,537.25 Semester LPN Step-Out Option 14 Contact Hours Tuition & Fees $ 2,282.00 $ 2,772.00 $ 2,964.50 Textbooks (approx.) $ 253.00 $ 253.00 $ 253.00 Malpractice Insurance $ 13.00 $ 13.00 $ 13.00 Boards $ 250.00 $ 250.00 $ 250.00 Kaplan Access $ 144.00 $ 144.00 $ 144.00 SEMESTER TOTAL $ 2,942.00 $ 3,432.00 $ 3,624.50 Semester FOUR Nursing Semester III 19.5 Contact Hours Tuition & Fees $ 3,178.50 $ 3,861.00 $ 4,129.13 Textbooks (required) $ 400.00 $ 400.00 $ 400.00 Malpractice Insurance $ 13.00 $ 13.00 $ 13.00 Kaplan Access $ 144.00 $ 144.00 $ 144.00 SEMESTER TOTAL $ 3,735.50 $ 4,418.00 $4,686.13
SOUTHWESTERN MICHIGAN COLLEGE SCHOOL OF NURSING & HEALT SERVICES ESTIMATED COST SHEET RN PROGRAM 2016-2017 ACADEMIC YEAR APPROXIMATE COST In-District In-State Out-State Semester FIVE Nursing Semester IV 22.5 Contact Hours Tuition & Fees $ 3,667.50 $ 4,455.00 $ 4,764.38 Textbooks (required) $ 450.00 $ 450.00 $ 450.00 Malpractice Insurance $ 13.00 $ 13.00 $ 13.00 Nursing Pin Priced according to gold make up ($60-$200) $ 150.00 $ 150.00 $ 150.00 Graduation Uniform and Cap $ 50.00 $ 50.00 $ 50.00 Boards $ 250.00 $ 250.00 $ 250.00 Kaplan Access $ 144.00 $ 144.00 $ 144.00 SEMESTER TOTAL $ 4,724.50 $ 5,512.00 $ 5,821.38 Recommended Electives 24 Contact Hours Tuition & Fees $ 3,912.00 $ 4,752.00 $ 5082.00 Textbooks (approx) $ 650.00 $ 650.00 $ 650.00 TOTAL $ 4,562.00 $ 5,402.00 $ 5,732.00 Approximate cost of A.D.N. program with prerequisites: These prices reflect the approximate cost in each area. Breakdown of Cost for LPN Step-Out Option: Semester ONE (Prerequisites) $ 3,871.00 $ 4,466.00 $ 4,699.75 Semester TWO $ 5,937.00 $ 6,972.00 $ 7,253.25 Semester THREE $ 3,685.50 $ 4,269.00 $ 4,537.25 Semester LPN $ 2,942.00 $ 3,432.00 $ 3,624.50 Non Sequential $ 2,606.00 $ 3,026.00 $ 3,191.00 PROGRAM TOTAL $ 19,041.50 $ 22,165.00 $ 23,305.75 Breakdown of Cost for RN: Semester ONE (Prerequisites) $ 3,871.00 $ 4,466.00 $ 4,699.75 Semester TWO $ 5,937.00 $ 6,972.00 $ 7,253.25 Semester THREE $ 3,685.50 $ 4,269.00 $ 4,537.25 Semester FOUR $ 3,735.50 $ 4,418.00 $ 4,686.13 Semester FIVE $ 4,724.50 $ 5,512.00 $ 5,821.38 Recommended Electives $ 4,562.00 $ 5,402.00 $ 5,732.00 PROGRAM TOTAL $26,515.50 $31,039.00 $ 32,729.76