RN-to-BSN PROGRAM APPLICATION Personal Information Please provide your legal name below Middle Social Security Number Date of Birth Email Gender Religious Preference I am applying for the term beginning: Information Zip/Postal Code Home Phone Number Cell Phone Number Is your mailing address the same as your permanent address? Yes No Citizenship (check all that apply) I am a: U.S. Citizen Permanent Resident Dual Citizen Non-U.S. Citizen U.S. Refugee or Asylee DACA Ethnicity Are you Hispanic or Latino? Yes No American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Family Member Education Did either of your parents graduate from a four-year college or university? Yes No
Family Member #1 Phone Number Is this person deceased? Yes No This person s address and mine are Same Different Family Member #2 Phone Number Is this person deceased? Yes No This person s address and mine are Same Different Family Information Please list the names of any family members who have attended the University of Portland. Please list the names and ages of all your siblings (if not listed above) and colleges or universities they have attended and/or degree earned. Age of College/University Postal Code Degree Earned Yes No
Age of College/University Postal Code Degree Earned Yes No Declaration of Major Have you previously applied to University of Portland? Yes No Please select an intended major Nursing Planned Career Goal College (s) Attended Cumulatively, have you completed 30 or more semester hours, or 45 or more quarter hours at another Yes No college or university? Have you earned or do you plan to earn a bachelor s degree prior to attending University of Portland? Yes No Degree Major Zip/Postal Code County Date Degree Awarded List all colleges and universities you have attended or are currently attending. Please list the most recently attended first: ZIP/Postal Code Date Attended Date Attended What type of college/university is this? Degree What was your GPA at this institution? (if known?)
ZIP/Postal Code Date Attended Date Attended What type of college/university is this? Degree What was your GPA at this institution? (if known?) Are you a member of Phi Theta Kappa? (PTK) Yes No Current Schedule Please list all courses you are taking or plan to take prior to enrolling in the RN to BSN program First Term Second Term Third Term High School Information ZIP/Postal Code Date of Graduation (mm/year) Your high school is: Public Private
Employment Please list any job(s) you have held during the past four years. Please include a copy of your resume with the application. Resumes can be emailed directly to fischer@up.edu in PDF format.
Goal Statement Essays Complete and attach all two essay questions, not to exceed 300 words for each question: Several factors influence nurses' pursuit of BSN education. The Institute of Medicine (IOM, 2011) has recommended that the percentage of nurses with a BSN or higher be increased by 80% by 2020. Additionally, in the Essentials of Baccalaureate Education for Professional Nursing Practice, the American Association of Colleges of Nursing (AACN,2008) advocates for nurses to commit to the health of vulnerable populations and work toward elimination of health disparities. o o Essay 1: Describe how the attainment of a BSN degree will impact your nursing contributions in your current work setting or organization. Essay 2: Describe specific reasons for pursuing your BSN from the University of Portland School of Nursing. Please identify people, events, or features that influenced your decision to apply to UP. Teacher/Counselor UP student Relative UP admissions representative UP alumni Brochures College Fair UP faculty or staff member Friend Visit to campus UP website Catholic affiliation Academic programs Other
Please read and check the boxes before submitting your application. Have you ever been dismissed, suspended, or placed on disciplinary probation by a high school or college/ Yes No University? If yes, explain: Have you ever been arrested or convicted of any violation? Yes No If yes, explain: At the time of the end of your enrollment at your current college/university, or Yes No if you are still a student, were you or are you currently the subject of a disciplinary or student conduct charge or proceeding? If yes, explain: Final Steps I understand that University of Portland must have an individual official transcript from every university or college I have attended. If you have questions about meeting this requirement, please call our School of Nursing at (503) 943-7211 or (800) 227-4568. I declare that all the information contained in my application is correct, complete, and honestly presented. Signature Student Date Completed