Lake Washington Institute of Technology WINTER SPRING FALL 2017-18 Nursing AAS-T Application and Forms This document contains the application form for the Nursing AAS-T program. It should also be used for re-application to the program. This application works in tandem with the Supporting Information document supplied at www.lwtech.edu/nursing under the heading advising and admission. You are responsible for reading all supporting information. Please allow adequate processing time for all documents and transcripts you need to submit to LWTech. In order to create a fair selection process, we will only consider application packets to be complete when they include all the necessary transcripts and other documents and have met the stated deadline. We do not contact applicants who have missing documents. Only students with completed applications will be considered for admissions to the LWTECH Nursing Program. It is the student s responsibility to make sure all requirements are met and all required documents are received for the application. You should download and print this application. To request disability accommodations in the application process, contact Disability Support Services: (425) 739-8300; Fax: (425) 739-8275; dssinfo@lwtech.edu. Step 1. Step 2. Read the Supporting Information document at www.lwtech.edu/nursing under the heading advising and admissions. It contains detailed information about the program prerequisites and other eligibility requirements. It will familiarize you with the selection criteria (points structure) used in admissions to this program. If you are a first time applicant, fill out this entire application and make copies of all materials you plan to mail or hand deliver to the Enrollment Services office. OR Step 3. If you are a re-applicant, read the Supporting Information document in its entirety at www.lwtech.edu/nursing Then, fill out only the pages in this application discussed in the re-applicant instructions and make copies of all materials you plan to mail or hand deliver to the Enrollment Services office. Application Packet Mailing Address: Hand Deliver Application Packet to: APPLICATION FOR ADMISSION NURSING AAS-T LAKE WASHINGTON INSTITUTE OF TECHNOLOGY 11605 132 ND AVENUE NE KIRKLAND, WASHINGTON 98034-8506 Enrollment Services West 201, (walk-up windows or Information Center) Materials must be in an envelope labeled APPLICATION FOR ADMISSION NURSING AAS-T and your name B783, B784, B892 1
PERSONAL INFORMATION LWTech Student ID #: Last Name First Name Middle Initial Address, including apartment number City State Zip Code Day Phone Ext. Evening Phone Ext. E-mail Address (Please Print Carefully) LWTECH student email: s-. @LWTECH.edu (first name) (last name) Name of last high school attended: Previous Names 1. 2. All email from Admissions will be sent to your LWTECH email account. This includes notification of selection results. Year graduated or completed GED: City, State, Country: EDUCATIONAL BACKGROUND Required to apply-complete information for each box-do not leave any box blank LWTech Course Number/Title College Name Other College Number/Title Term/Year Credits Grade BIOL&241 Anatomy& Phys. I BIOL&242 Anatomy & Phys. II ENGL&101 Written Expression MATH&146 Statistics PSYC&200 Lifespan Psychology CHEM&121 Intro to Chemistry Optional to apply-complete information for each box If admitted to the nursing program courses must be completed by the start of the 5 th quarter of nursing classes LWTech Course Number/Title BIOL&260 Microbiology CMST&210,220, or 230 Communication NUTR&101 College Name Other College Number/Title Term/Year Credits Grade B783, B784, B892 2
Nutrition Prior degree or certificate is: (Optional) Prior degree/certificate was earned where?: (Optional) I have Junior standing at a four year college or university: YES (Optional) B783, B784, B892 3
MANDATORY CHECKLIST Official transcripts for all classes listed on page 2. Official transcripts are used to verify program/certificate/degree for Prior Education points and Proof of Certification in a Healthcare Profession if applicable. International transcripts must be agency assessed. Do not submit LWTech transcripts. TEAS V. 5 or new ATI TEAS scores that are less than 2 years old submitted to ATI database for LWTech viewing. Applicants must pay a fee to ATI if the test was not taken at LWTECH in order for LWTECH admissions staff to view scores. Please enter your score and the date of your test: Date taken: Composite Score: Two sealed/signed professional recommendation forms. One recommendation must be from a Faculty who taught you in a college course. The second can be a Supervisor or Co- Worker Copy of current Certified Nursing Assistant license or Current LPN License, Medical Assistant License or Military JST for military nurse or Corpsman Checklist continued I am a re-applicant: I most recently applied in (year) (quarter) I am submitting my Certified Nursing Assistant license or Current LPN License, Medical Assistant License or Military JST for military nurse or Corpsman: I am submitting new TEAS V. 5 scores or New ATI TEAS scores yes or No I am submitting a new essay: yes or No use score from: quarter : Year: I am submitting new Transcripts yes or No from: 1. 2. I am submitting new recommendations from: Faculty: provide name: Supervisor: provide name: Coworker: provide name: Please re-use the following recommendations: Faculty: provide name: Supervisor: provide name: Coworker: provide name: If a re-applicant does not designate which recommendations to use for the current application, scores from the most recent application will be used. B783, B784, B892 4
High school diploma or GED completion information as listed on p.2 (do not submit transcripts or copies of diplomas) Short answer essay per instructions on p. 7 of Supporting Information document This fully completed checklist (p. 2-5 is required in my application packet) Applicant s Certification: I certify that all statements in this application are true to the best of my knowledge. I verify that all requirements indicated above have been completed and are included in my admissions packet. I have kept a copy of this application for my records. Signature: Date Lake Washington Institute of Technology does not discriminate on the basis of race or ethnicity, creed, color, national origin, sex, marital status, sexual orientation, age, religion, disability, genetic information, or veteran status. Response or non-response to any of the questions listed as voluntary in this application will not affect your consideration for admission. Jurisdiction 7.P.47 WAC 495D-121-320 The student conduct code shall apply to student conduct that occurs on or off campus and at or in connection with college sponsored activities. Students are responsible for their conduct from the time of application for admission through the actual receipt of a degree, even though conduct may occur before classes begin or after classes end, and during the academic year and during periods between terms of actual enrollment. These standards shall apply to a student s conduct even if the student withdraws from college while a disciplinary matter is pending. The college has sole discretion, on a case by case basis, to determine whether the student conduct code will be applied to conduct that occurs off-campus. B783, B784, B892 5
LAKE WASHINGTON INSTITUTE OF TECHNOLOGY NURSING PROGRAMS RECOMMENDATION FORM PAGE 1 FACULTY RECOMMENDATION To Applicant: Do not submit letters of recommendation (this form is required). Complete section A and then give this form to the person completing your recommendation, along with an envelope addressed to you. When you receive your completed, sealed recommendation forms, leave them in the signed envelope and include with your nursing program application packet. A. APPLICANT INFORMATION (this section is to be completed by the applicant. Please print.) Last Name First Name Middle Initial Today s Date Previous Last Name(s) Birth date (Month/Day/Year) Name of Recommender Recommender s Telephone Number Address of Recommender (Street) (City) (State and ZIP Code) In what capacity have you known the Recommender? Instructor/Faculty According to the Family and Educational Rights and Privacy Act of 1974, as amended, students are guaranteed access to educational records concerning them, unless that right is waived. Your signature below is optional: however, you (applicant) should check with recommender to ensure that he/she is willing to submit this form without the guarantee of confidentiality. I hereby waive any and all rights to inspect and review this recommendation, and I give my permission for this reference to remain confidential between Lake Washington Institute of Technology and the recommender. Signature of Applicant Date To the Recommender: The applicant is seeking admission to the nursing program at Lake Washington Institute of Technology. To help us assess the applicant s ability to successfully complete this program, we would appreciate your candid opinion regarding the qualities listed on the front and back of this form. Please return this form in the envelope provided to you by the applicant. Thank you, Nursing Program Evaluation Committee B. ACADEMIC HISTORY (The following sections are to be completed by the Recommender.) Recommender: Please respond to this academic section only if you have knowledge of the applicant s academic history.) Does the applicant s academic history indicate probable success in the LWTech nursing program? Yes If not, please explain. C. GENERAL COMMENTS No B783, B784, B892 6
D. RECOMMENDER INFORMATION- RECOMMENDATION FORM -PAGE 2 How long have you known the applicant? Indicate your evaluation of applicant by checking the appropriate rating. Initiative Responsibility Leadership Interpersonal skills Integrity Ability to analyze problems Written communication Oral communication Adaptability Risk-taking Creativity Clinical competence (if known) Commitment to ethnic and cultural diversity Ability to handle conflict Ability to handle stress Ability to work with others as a team Judgment and common sense Acceptance of feedback Ability to see the Big Picture Perseverance Self confidence Self direction Reliability Ability to build a sense of community E. RECOMMENDATION I strongly recommend the applicant for admission without reservation I recommend the applicant with some reservation F. SIGNATURE Exceptional Superior Above average Average Below average I recommend the applicant for admission Fair I do not recommend the applicant for admission Unable to evaluate Signature of Recommender Today s Date Printed Name of Recommender Recommender s Telephone Number Title Name of Organization Address(Street) (City) (State and ZIP Code) B783, B784, B892 7
LAKE WASHINGTON INSTITUTE OF TECHNOLOGY NURSING PROGRAMS RECOMMENDATION FORM PAGE 1 To Applicant: Do not submit letters of recommendation (this form is required). Complete section A and then give this form to the person completing your recommendation, along with an envelope addressed to you. When you receive your completed, sealed recommendation forms, leave them in the signed envelope and include with your nursing program application packet. A. APPLICANT INFORMATION (this section is to be completed by the applicant. Please print.) Last Name First Name Middle Initial Today s Date Previous Last Name(s) Birth date (Month/Day/Year) Name of Recommender Recommender s Telephone Number Address of Recommender (Street) (City) (State and ZIP Code) In what capacity have you known the Recommender? Supervisor Co-worker: According to the Family and Educational Rights and Privacy Act of 1974, as amended, students are guaranteed access to educational records concerning them, unless that right is waived. Your signature below is optional: however, you (applicant) should check with recommender to ensure that he/she is willing to submit this form without the guarantee of confidentiality. I hereby waive any and all rights to inspect and review this recommendation, and I give my permission for this reference to remain confidential between Lake Washington Institute of Technology and the recommender. Signature of Applicant Date To the Recommender: The applicant is seeking admission to the nursing program at Lake Washington Institute of Technology. To help us assess the applicant s ability to successfully complete this program, we would appreciate your candid opinion regarding the qualities listed on the front and back of this form. Please return this form in the envelope provided to you by the applicant. Thank you, Nursing Program Evaluation Committee B. ACADEMIC HISTORY (The following sections are to be completed by the Recommender.) Recommender: Please respond to this academic section only if you have knowledge of the applicant s academic history.) Does the applicant s academic history indicate probable success in the LWTech nursing program? Yes If not, please explain. C. GENERAL COMMENTS No B783, B784, B892 8
D. RECOMMENDER INFORMATION- RECOMMENDATION FORM -PAGE 2 How long have you known the applicant? Indicate your evaluation of applicant by checking the appropriate rating. Initiative Responsibility Leadership Interpersonal skills Integrity Ability to analyze problems Written communication Oral communication Adaptability Risk-taking Creativity Clinical competence (if known) Commitment to ethnic and cultural diversity Ability to handle conflict Ability to handle stress Ability to work with others as a team Judgment and common sense Acceptance of feedback Ability to see the Big Picture Perseverance Self confidence Self direction Reliability Ability to build a sense of community E. RECOMMENDATION I strongly recommend the applicant for admission without reservation I recommend the applicant with some reservation F. SIGNATURE Exceptional Superior Above average Average Below average I recommend the applicant for admission Fair I do not recommend the applicant for admission Unable to evaluate Signature of Recommender Today s Date Printed Name of Recommender Recommender s Telephone Number Title Name of Organization Address(Street) (City) (State and ZIP Code) B783, B784, B892 9