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STUDENTS ARE RESPONSIBLE FOR THEIR OWN HEALTH INSURANCE

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NORTH ARKANSAS COLLEGE

Department of Nursing & Allied Health Programs

Application for Admission

LPN-RN-Associate Degree (AAS) Program

Part A

Demographic Data

Date: First Application

 Second Application  Third Application  Programs Applying for: Other Allied Health RN Student Reapplication to Program  Transfer from: (Name of School)

Northark Student ID: Social Security Number:

RT ST   MLT Paramedic  

Last Name: First: Middle: Maiden:

Address: City: State: Zip:

Boone County Resident Yes  No 

Home Phone: Cell Phone: Northark E-mail address: US Citizenship

Yes  No 

Work Phone: Message Phone: Personal E-mail address:

Part B

Personal Health Information Gender:

M  F 

Date of Birth: Age: Person to notify in case of emergency: Relationship:

Home Phone: Work Phone: Physician Name: Address: City, State Zip: Physicians Phone:

STUDENTS ARE RESPONSIBLE FOR THEIR OWN HEALTH INSURANCE

Have you ever had: Do you presently have:

Yes No Yes No Orthopedic Problems Yes No Yes No Chemical Dependency

Yes No Yes No Chronic Communicable Disease Yes No Yes No Psychiatric Problems

Yes No Yes No Dental Problems Yes No Yes No Neurological Problems

Yes No Yes No Other significant health problems

Any physical defects or limitations? Yes___ No___ If “Yes”, then please describe any health problems on the back of this sheet. Include duration, treatments and resolution of the problem(s).

Medical clearance is required on any health problem that could interfere with the ability of the student to meet the performance criteria of the program, endanger the safety of a client and/or jeopardize the health of the student if he/she attempts to meet the performance criteria.

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There is no health insurance coverage provided for students by either the clinical facilities or North Arkansas College. Students are expected to be personally responsible for treatment needed due to accidental injury or health risks. Students are strongly advised to purchase personal health insurance and are encouraged to take the hepatitis B vaccine.

I understand that there are performance criteria (critical requirements) established for skills taught and that all students are expected to master these skills, e.g. psychomotor skills include: cardiopulmonary resuscitation for health care providers and the transfer of clients, which requires lifting and moving, according to the performance criteria. _________________________________ ______________________

Student Signature Date

TO BE COMPLETED ONLY IF MEDICAL CLEARANCE IS NEEDED:

I have examined ____________________________________________ and give him/her medical clearance to enroll in the nursing program at North Arkansas College.

___________________________________ _____________________ Signature of Physician Date

Description of Health Problems (if applicable):

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Part C

Required Records

North Arkansas College Application Submitted

Yes  No 

Transcripts Submitted Yes  No 

If you have not already done so, please request that all transcripts, high school, GED, and ACT scores, college or colleges, LPN School or other, be sent directly to the

ADMISSIONS OFFICE NORTH ARKANSAS COLLEGE

1515 Pioneer Drive Harrison, Arkansas 72601

from the respective institutions, bearing the imprint of the institution's seal (official transcript).

Include official High School transcript or documentation of GED.

All transcripts must be received before application deadline to be considered.

Include a copy of current professional health related license(s). State of Licensure(s):

CNA  Paramedic  LPN  Other  If Licensed Practical or Vocational Nurse LPN or LVN

______________________________________________ __________________________________________ Name of School Address

Date of Attendance ___________________________ Date of Graduation _______________________

List college(s) attended.

1. ________________________________________________________________________________________ Name of College Complete Address (if known)

________________________________________________________________________________________ Dates of Attendance Date of Graduation Degree/Credit Earned 2. ________________________________________________________________________________________

Name of College Complete Address (if known)

________________________________________________________________________________________ Dates of Attendance Date of Graduation Degree/Credit Earned 3. ________________________________________________________________________________________

Name of College Complete Address (if known)

________________________________________________________________________________________ Dates of Attendance Date of Graduation Degree/Credit Earned

Note: If more than 3 colleges use separate sheet with above information.

Work Experience—LIST CURRENT EXPERIENCE FIRST (include nursing, or related work experience, business or

other)

1. ______________________________________________________________________________________________________________

Name of Employer Address Position Dates of Employment

Reason for Leaving ______________________________________________________________________________________________ 2. ______________________________________________________________________________________________________________

Name of Employer Address Position Dates of Employment

Reason for Leaving ______________________________________________________________________________________________ 3. ______________________________________________________________________________________________________________

Name of Employer Address Position Dates of Employment

Reason for Leaving ______________________________________________________________________________________________ 4. ______________________________________________________________________________________________________________

Name of Employer Address Position Dates of Employment

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Please submit the following with this application to:

RN Program Director North Arkansas College

1515 Pioneer Drive Harrison, AR 72601

 Copy of current unencumbered LPN license number for verification.

 Evidence of at least 3 months or 120 hours of work experience within the last year and job description as a LPN from the Director of Nursing Services (or equivalent) on letterhead stationary from the facility.

 Work Verification Form-The work requirement may be waived if the applicant has graduated from a PN program in the previous year before application. The applicant must obtain a letter of recommendation from a PN instructor or the PN Director.

 Attach MMR’s if you have not already submitted to the College. Those born after 1/1/57 must furnish proof of measles and rubella vaccines that have been received after the first birthday and after 1/1/68. Two MMR’s or a positive Rubella titer for antibodies is a standard requirement.

If you have a current copy of the following please submit with your application:

 Tuberculin skin test (TB)—2 within the last year (two-step or annual).  CPR certification (American Heart Association-Healthcare Provider) Current and up to date immunizations:

 Tdap within the last 10 years  Varicella

 Hepatitis B

10 Panel UA Drug Screen (details will be given at orientation if accepted into program)

These documents will be required upon acceptance into the program.

Falsification of any information in this application may result in dismissal from the program.

I have_____ have not_____ pled guilty or nolo contendore or been convicted of a crime or offense listed in Act 1208 of 1999 in the state of Arkansas.

I have_____ do not have_____ any criminal convictions in expunged or sealed records (these records are discoverable by RN Licensing Boards). If yes, explain:

_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

See statement below for signature:

My signature indicates that I have read Act 1208 of 1999 and I understand if I graduate from the RN program at North Arkansas College I may not be able to sit for the licensure exam (NCLEX-RN) if I have pleaded guilty or nolo contendore to, or been found guilty of any of the offenses listed in the Act.

__________________________________________________________________

__________________________

Signature Date

Revised 7/2015

Page 4 of 4

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LPN greater than 3 months in length or 120 hours. Documentation of work history, which must

include job description, must be provided on the form from North Arkansas College Department of

Nursing. The Director of Nursing or the RN manager should fill out the form and sign the form

verifying authenticity. The form should be mailed directly to the RN nursing department in a sealed

envelope to the following address:

North Arkansas College

Department of Nursing

ATTN: Kim Tinsley, MSN, RN, CNE

LPN-RN Director

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Department of Nursing

Verification of Work History and Recommendation

LPN-RN Applicants

LPN-RN Applicants Name______________________________ Date____________

Briefly describe the job duties of the LPN who is applying for a position in the LPN-RN Bridge Program:

________________________________________________________________________________________ 

________________________________________________________________________________________ 

________________________________________________________________________________________ 

Hire Date____________________________ OR PN program attendance dates_______________________

Is the applicant currently employed by this facility?

YES

NO (if no supply end date)

Please describe the LPN-RN applicant’s work ethic:_______________________________________________

________________________________________________________________________________________ 

________________________________________________________________________________________ 

________________________________________________________________________________________ 

Would you recommend the applicant to be considered for the LPN-RN Bridge Program?

YES

NO (if no, then please provide reason in space below)

Signature________________________________________________ Title_________________________

Please mail this form directly to:

North Arkansas College

Department of Nursing

ATTN: Kim Tinsley, MSN, RN, CNE

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Please use the provided transcript request form in order to have official transcripts

sent to the Admission’s Office at Northark. Only official transcripts will be

considered, and the deadline for receiving information is September 1.

Good Luck on your application process,

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Date ________________________________

Please send an official transcript of my credits to:

Admission’s Office North Arkansas College

1515 Pioneer Drive Harrison AR 72601

If any charge, please bill me at the address below.

_____________________________________________________________________________________ Last Name First Middle Maiden

_____________________________________________________________________________________ Mailing Address

_____________________________________________________________________________________

City State Zip Code

____________________________________________________________________________________ Date of Birth Dates of Attendance Social Security No.

__________________________________________ PLEASE ATTACH THIS FORM

Signature TO TRANSCRIPT

Date ________________________________

Please send an official transcript of my credits to:

Admission’s Office North Arkansas College

1515 Pioneer Drive Harrison, AR 72601

If any charge, please bill me at the address below.

_____________________________________________________________________________________ Last Name First Middle Maiden

_____________________________________________________________________________________ Mailing Address

_____________________________________________________________________________________

City State Zip Code

____________________________________________________________________________________ Date of Birth Dates of Attendance Social Security No.

__________________________________________ PLEASE ATTACH THIS FORM

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