COLLEGE OF NURSING
APPLICATION FOR ADMISSION
NURSING PROGRAMS
*Applications accepted for admission for Fall Semester Sept 1 – April 1 for 1st year of ADN and PN *Application selection will be Nov/Dec. 15 and April/May 15th for 1st year ADN/PN
Applications accepted for admission to Fall Semester Sept. 1- July 30th for LPN to RN program *Application selection will be Nov/Dec. 15, April/May 15th and July 31st for LPN-RN
*An application fee of $50.00 is required when you submit the application. Submit your application to Carl Sandburg College, College of Nursing, 2400 Tom L. Wilson Blvd., Galesburg, Illinois 61401 (All fees must be paid to the Business Office)
Date ______________________, 20_____
______1st YEAR OF ASSOCIATE DEGREE (RN) _______2nd YEAR OF ASSOCIATE DEGREE (RN) ______LPN TO RN ARTICULATION _______PRACTICAL NURSING DAYS
______PRACTICAL NURSING EVENING
*You may apply for more than one program. You must rank your preference for admission to each program you apply for (1st, 2nd, etc.). When the selection committee meets and it has been determined that you have met the criteria for your preference in order of ranking; you will be notified of your conditional admission to that program and be removed from the admission list of the other programs you have applied to. You will have 14 calendar days to pay the $50.00 placement (seat) fee to the business office to hold your seat in the program after notification of conditional admission.
The $50.00 application fee is non-refundable and will be applied to a scholarship fund for nursing. The $50.00 (intent to enter)seat fee will be refunded or applied to your tuition if you enter the program.(All fees to be paid to the Business Office only-do not return with your application)
Print name in full:
Last Name First Name Middle Name (Maiden Name) _____________________________________________________________________________________ Address City State Zip Code
_____________________________________________________________________________________ Phone Number Alternate Phone Number
_____________________________________________________________________________________ Social Security Number Email
____________________________ _______________________________________ Date of Birth Student I.D. Number (Carl Sandburg College)
2 Items 1, 2, and 3 are optional. Request of information is for purposes of completing accreditation reports.
1. Ethnic Origin (check one):
Caucasian, Non-‐ Hispanic African-‐American Hispanic American Indian Asian or Pacific Islander Alaska Native Other
2. Gender: Male Female
3. Highest Level of Education Achieved_____________ Major ______(if applicable)
4. Please list any schools of nursing you have previously attended and give the following information:
Name of School (s)
City and State
______________________________________________________________________________ Date of Entrance Date of Leaving
____________________________________________________________________________ Reason for leaving (Please use additional paper if you previously attended more than one nursing school)
5. Have you ever applied to Carl Sandburg Nursing Programs?
Yes No
6. Upon completion of all prerequisites, when do you plan to be formally admitted to the Nursing Program?
Fall 20_____
7. Have you spoken with a counselor/advisor? Yes No
8. If so, who? _______________________________________ When________________________
9. Have you taken the TEAS test: Yes No When_________ Where_________
10. Are you currently on the Illinois CNA Registry Yes No (If yes, include a copy of your Registry certificate with your application)
Listed below are all the prerequisite, and courses required for the nursing programs. Please check whether you have completed (with a “C” or better) or are in progress. If the course is in progress, write “IP” and the semester. If you have completed the course, list the date and where. This will assist you, your nursing advisor, and the college of nursing to expedite your application (All courses will be validated by official transcripts through the Admissions/Records Office).
*Courses with a * are PN program requirements. (For PN who wish to consider articulation to the AD program they may wish to take BIO 211 and BIO 212 instead of BIO 111).
+Courses with a + are required for the RN program
COURSE TAKEN/IP Grade Earned Biology (1 year of HS or 1 semester of college) * + Chemistry (1 yr. of HS or 1 sem. of college) + NUA 100 Basic Nurse Assistant Training * + ENG 101 Freshman Composition I *+ PSY 101 General Psychology I*+ PSY 265 Developmental Psychology*+ BIO 111 Anatomy & Physiology Fundamentals* BIO 211 Anatomy & Physiology I + BIO 212 Anatomy & Physiology II + NUT 110 Nutrition* + BIO 200 General Microbiology + SOC 101 Introduction to Sociology + PHL 103 Biomedical Ethics +
*A grade of “C” or higher is required in all required courses to progress in the program.
By signing below, you acknowledge you must participate in a required “Informational Session” and full admission to the nursing program is provisional on meeting all the requirements necessary for admission to the selected nursing program.
*Dates of registration for Informational Sessions will be included in your letter of Conditional Admission.
________________________________________________ ______________________________ Student Signature Date
Note: The College of Nursing is asking you to provide information that includes private and/or confidential information under state and federal law. The college of nursing is asking for this information in order to process your application. You are not legally required to provide the information the college of nursing is requesting; however, the college of nursing may not be able to effectively process your application if you do not provide sufficient information. With some exceptions, unless you consent to further release of private information, access to this information will be limited to school officials, including faculty who have legitimate educational interests in the information. Under certain circumstances, federal and state laws may authorize release of private information without your consent.
4 After all requirements for conditional admission have been met the student will be notified by mail with instructions for full admission status.
After all the requirements for full admission have been met the student will be notified by mail with final instructions for entry into the program.
Having submitted my application to the College of Nursing; I understand the admission requirements for this program. I accept responsibility for the completeness of my application and any additional requirements for full admission to the program.
I understand the program has selective admission.
I understand that information acquired by the program throughout my admission process (background check, drug screen, etc.) may make me ineligible for admission to the program or subject to withdrawing from the program.
_________________________________________________ ____________________
Student Signature DateAdmission Checklist
_________Complete a general application for admission to Carl Sandburg College
_________Complete College Compass test
_________Request all high school and college transcripts be sent to Carl Sandburg College
Admissions and Records Office.
_________Print and Complete an application for Nursing: mail/or return
Pages 1-‐3
to
:
Carl Sandburg College
College of Nursing
Building AA
2400 Tom L. Wilson Blvd
Galesburg, Illinois 61401
__________Pay a $50.00 Nursing Application fee in the Business Office(Send or take application
fee form with you to the Business Office)
__________Take a copy of your Nursing Application to your meeting with an Advisor
__________Make an appointment with an Advisor
Phil Jennings
pjennings@sandburg.edu
or 309-‐341-‐5483 -‐ Galesburg
Megan Jones
mjones@sandburg.edu
or 309-‐341-‐5229 – Galesburg
Ellen Henderson-‐Gasser
ehenderson@sandburg.edu
or 217-‐357-‐3129,
ext. 7247 – Carthage/Bushnell
__________Make an appointment to take the TEAS test (TEAS V)
(If you took the TEAS at other institutions, you need to request an official transcript
through ATI. A copy of your score report will not be accepted.)
__________Register and attend a required “Informational Session” after notification of
Conditional Admission.
__________Pay $50.00 intent (seat) fee to hold your position in the Nursing Program.
You will have 14 days to pay your fee to the Business Office after notification of your conditional admission to the program.
__________Register for Nursing Program during the “Informational Session” (may also register
for any general education courses, etc. at this time).
6
__________ Submit all required forms for Full Admission to the Nursing Program (specific
Forms will be given out at the “Information Session”). (
Health Evaluation,
Background Check and Drug Screening must occur no sooner than three (3)
months prior to entering the program
)
______Health Evaluation with Immunity requirements/ 2-‐step TB test
______Criminal Background Check
______Drug testing/screening/
______Copy of CPR (dates discussed at Informational Session)
______Copy of Illinois Nurse Assistant Registry
Copy of current Illinois LPN license if applying to LPN-‐AD
Signed HIPAA form (see website for information)
Signed Confidentiality Form
Signed Statement of Good Health Form
Disclosure Statement
Release of Results for Drug Screen (original to agency doing drug
screen-‐copy to nursing program)
Reference Release Form
Abilities and Skills Required Form
Deadline for submission of all forms/requirements for Fall start date is June 30
th.
(Alternates will be given additional time if notified after June 30
th)
_____/_____Total Points Earned for Admission Selection
___________After all required forms/documents have been received and accepted you will be
notified by
.
Having submitted my application to the College of Nursing; I understand the admission
requirements for this program. I accept responsibility for the completeness of my application
and any additional requirements for full admission to the program.
I understand the program has selective admission.
I understand that information acquired by the program throughout my admission process
(background check, drug screen, etc) may make me ineligible for admission to the program or
subject to withdrawing from the program.
*This form is to be used as your checklist for completion of all requirements:
Please print a
copy for yourself to use.
College of Nursing
Application Fee Form
Nursing Program Application Fee: $50.00
You can pay the application fee by check, cash, credit or debit card, or money order, etc. This form must accompany the application fee payment. Your application will not
be processed until the fee is received. The application fee is nonrefundable. *Do not
send Nursing Application to the Business Office
Instructions: 1) Print the Application Fee Form
Select Payment Option: __Check here if you are paying by personal check.
__Check here if you are paying by credit/debit card.
__ Check here if paying by another method.________
Make check/money order payable to: Carl Sandburg
College (Do not send CASH)
