CALIFORNIA STATE UNIVERSITY, STANISLAUS School of Nursing, Application to the ASBSN Program

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School of Nursing, Stockton Campus 612 East Magnolia Street

Stockton, CA 95202-1846 Phone: 209-664-4435

Application Period Ends Friday May 16, 2014 5 pm – all materials must have been received at the

Stockton Campus (not postmarked)

The application process requires 2 applications. Both must be returned at the same time.

Application 1: Apply to the ASBSN Program in the School of Nursing

• Submit this Application to the Nursing School for the ASBSN Program.

• A $55.00 program application fee is required (nonrefundable). Make checks or Money orders payable to:

CSU Stanislaus

• Official transcripts from each college or university attended after high school including, CSU

Stanislaus. (1 copy of official transcripts if available)

• If official copies are NOT available, you may include unofficial copies with your application.

• If you need to order official transcripts, do so immediately. Have them sent to the address below.

DO NOT have them sent to the main Turlock campus. This will delay your application.

Note: We will not review any application without transcripts Additional Instructions:

Course Descriptions - Include a copy of catalog descriptions for any prerequisite courses that do not appear on our Equivalency grid. Some may be found at www.csustan.edu/nursing or www.assist.org

Statistical Data Form – included with application

Test – ATI (TEAS) is a pre-admission test that is required for all students applying to the nursing program.

• If you take the ATI (TEAS) test here at CSU Stanislaus, the results are automatically sent to us.

• If you have taken the TEAS exam before, please include your results with this application

• If you take the ATI (TEAS) test elsewhere, official results must be sent to us from ATI.

• You may use the highest score of your first 3 attempts of the ATI (TEAS) test

• Only the ATI (TEAS) version V score will be accepted

• You must have a minimum of 75% (version V) in the Adjusted Individual Total Score in order to qualify.

• Registration information can be found at: https://www.atitesting.com/Home.aspx Foreign Language Proficiency (if bilingual)

• Please complete the certification of Language Proficiency Form

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Application 2: Complete the CSU Stanislaus University application.

• Complete and submit the CSU Stanislaus University Application

• Pay the $55.00 University Application Fee. (non-refundable)

• Mail all your completed applications to:

CSU Stanislaus, Stockton Center School of Nursing ASBSN Program 612 East Magnolia Street

Stockton, CA 95202-1846

• Please include with your complete applications, 1 stamped Business Size Envelope with your return address.

Important

Only after you have been notified of conditional acceptance to the program, will you be asked to:

• Return your acceptance letter, registration form and $200.00 (non-refundable) program deposit fee.

• The $200.00 program deposit fee will be credited toward your total tuition fees account balance.

All application materials are available on our website: www.extendeded.com

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Student#

(or Date of Birth)

Name (Last) (First) (Middle) (Alias/Maiden)

Address (Number & Street) (City) (State) (Zip)

Mailing Address if different: (Number & Street) (City) (State) (Zip)

Preferred Phone #: ( ) - Work phone: ( )

Work Phone Optional

Alternate Phone #: ( ) - Email:

If you change your contact information, please notify the School of Nursing as well as the office of Enrollment Services.

1.

Status at the time of application (check all that apply)

a. A graduate of any CSU Campus Name of campus b. A post-baccalaureate student. Major

c. Permanent Residency in

Date of Degree

Calaveras County Merced County Stanislaus County Mariposa County San Joaquin County Tuolumne County Other

2.

Are you bilingual? Yes No Language:

If yes, please complete the Certification of Language Proficiency form, included with the application.

3.

Country of Citizenship

If you are not a citizen of the United States you must attach a photocopy of both sides of your Alien Registration Card and/or INS documentation (students under 19 years old must attach their parent’s INS documentation). The Board of Registered Nurses requires that all NCLEX-RN test takers have a Social Security Number at the time they take the NCLEX- RN test. If you do not have a Social Security Number you may not be eligible for licensure as an RN.

4.

Have you had any experience with health care, either volunteer or paid? Yes No If yes, please complete page 5 of this application.

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Have you ever been or are you currently enrolled in a nursing program? Yes No If yes, (Answer all that apply)

Name of school/college/university:

Reason for leaving the program:

Did you leave or are you leaving in good standing? Yes No (If yes, a letter of good standing must be submitted)

What types of program are/were you enrolled in?

LVN - Dates attended: still attending? Yes No

Associate Degree - Dates attended: still attending? Yes No Diploma Program - Dates attended: still attending? Yes No Baccalaureate Degree - Dates attended:

Other - Dates attended:

still attending? Yes No still attending? Yes No

5.

Have you ever applied to our Pre-licensure program? Yes No

(You are not penalized for previous applications; this helps us locate your previous records if needed) If yes, for what semester did you apply? Fall of or Spring of

6.

Have you taken the ATI (TEAS) test?

Yes-Approximate date sent

What was the Highest Score of your first 3 attempts % (If Known)

7.

No Date and location you will be taking

 Note: Only the highest ATI score of the applicants first 3 attempts will be used.

You must have a minimum of 75% (version V) in the Adjusted Individual Total Score in order to qualify for admission.

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Health Care Experience Form

HEALTH CARE AGENCY NAME & ADDRESS DATES

FROM DATES TO

APPROX # HOURS EACH

WEEK

SUPERVISOR &

PHONE NUMBER

Position/Title:

Briefly describe your responsibilities (use separate sheet of paper if necessary)____ Paid Volunteer

HEALTH CARE AGENCY NAME & ADDRESS DATES

FROM DATES TO

APPROX # HOURS EACH

WEEK

SUPERVISOR &

PHONE NUMBER

Position/Title:

Briefly describe your responsibilities (use separate sheet of paper if necessary) Paid Volunteer

HEALTH CARE AGENCY NAME & ADDRESS DATES

FROM DATES TO

APPROX # HOURS EACH

WEEK

SUPERVISOR &

PHONE NUMBER

Position/Title:

Briefly describe your responsibilities (use separate sheet of paper if necessary) Paid Volunteer

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PLEASE COMPLETE THIS ENTIRE DOCUMENT. FAILURE TO DO SO WILL RESULT IN A DELAY IN PROCESSING. ALL PREREQUISITES MUST BE COMPLETED PRIOR TO THE PROGRAM START DATE. PREFERENCE WILL BE GIVEN TO THOSE WHO HAVE MET ALL OF THE REQUIREMENTS LISTED BELOW.

• OVERALL GPA OF 3.0

• SCIENCE PREREQUISITE GPA OF 3.0 & higher

• OTHER NON-SCIENCE PREREQUISITE GPA OF 2.75 & higher

• GRADE OF “C” OR BETTER IN ALL PREREQUISITE COURSES

• NO MORE THAN 2 PREREQUISITE COURSES MAY BE REPEATED (one science and one non-science)

• NO PREREQUISITE COURSE MAY BE TAKEN MORE THAN TWICE

PREREQUISITE COURSE SCIENCE

INSTITUTION WHERE TAKEN

COURSE NAME

AND NUMBER

TERM/YEAR TAKEN

UNITS QTR OR SEMESTER

GRADE

FOR OFFICE

USE ONLY CHEMISTRY:

General, Inorganic, Organic or

Integrated (with lab if required)

UNITS QTR OR SEMESTER

GRADE LECTURE GRADE

LAB ANATOMY

W/LAB

UNITS QTR OR SEMESTER

GRADE LECTURE GRADE

LAB PHYSIOLOGY

W/LAB

UNITS QTR OR SEMESTER

GRADE LECTURE GRADE

LAB COMBINED

ANATOMY/PHYSIOLOGY W/LAB

UNITS QTR OR SEMESTER

GRADE LECTURE GRADE

LAB MICROBIOLOGY

W/LAB

UNITS QTR OR SEMESTER

GRADE LECTURE GRADE

LAB

If a course is “in progress” please note that in the grade column with an IP.

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CALIFORNIA STATE UNIVERSITY, STANISLAUS – NURSING PREREQUISITES CON’T

PREREQUISITE COURSE SCIENCE

INSTITUTION WHERE TAKEN

COURSE NAME AND

NUMBER

TERM/YEAR TAKEN

UNITS QTR OR SEMESTER

GRADE

FOR OFFICE

USE ONLY ENGLISH

COMPOSITION

UNITS QTR OR SEMESTER

GRADE

CRITICAL THINKING/INQUIRY

UNITS QTR OR SEMESTER

GRADE

GROUP DISCUSSION OR

PUBLIC SPEAKING

UNITS QTR OR SEMESTER

GRADE

MATH/STATISTICS

UNITS QTR OR SEMESTER

GRADE

INTRODUCTION TO PSYCHOLOGY

(co-requisite )

UNITS QTR OR SEMESTER

GRADE

Introduction to Sociology or Cultural

Anthropology (co-requisite)

UNITS QTR OR SEMESTER

GRADE

If a course is “in progress” please note that in the grade column with an IP.

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CERTIFICATION OF LANGUAGE PROFICIENCY

(Proficiency in English and One Other Language)

Instructions to the applicant: This form is OPTIONAL and is not required to be considered for admission to the Nursing degree program. If you qualify, submit this form with your application for the additional admission points.

SECTION I

Student completes this section

Applicant Name Student #

SECTION II

The person completing this language proficiency certification:

1. must be fluent in the identified foreign language and

2. must have known the applicant and observed his/her language skills in the past year.

3. must not be a close family member or friend.

Certification of proficiency in the language of .

Name

Title

Organization

Address , State . Zip

Phone

1. How long have you known the applicant and in what capacity?

2. How often have you observed the applicant conversing/translating in this language?

Daily 2+ days per week 1 day a week Other:

In each of the following questions, please rate the applicant on a scale from 1(low) to 5 (high):

1 = inadequate second language proficiency for professional communication 3 = able to translate in a medical emergency

5 = highly competent in speaking and writing proficiency

1 2 3 4 5

3. Applicant’s proficiency in speaking this second language is

:

4. Applicant’s proficiency in writing this second language is:

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Check List

Enclose a two $55.00 checks or money orders for the non-refundable and non-

transferable program application fee and University application fee.

Transcripts from each college or university attended after high school including

CSU Stanislaus. (1 copy of official transcripts if available)

Statistical Data Form

One (1) stamped, self-addressed envelope.

ATI TEAS test results sent from www.atitesting.com.

Provide your CSU, Stanislaus student I.D. number or application number if applicable.

Be sure course descriptions have been included if required.

Optional: Certification of language Proficiency

Optional: Honorably discharged Veterans. Please include a copy of your DD214.

Make checks or money orders payable to: CSU

Stanislaus You may hand carry or mail application to:

CSU Stanislaus Stockton Campus ASBSN Program School of Nursing, 612 East Magnolia St.

Stockton, CA 95202-1846

Nursing is a profession which requires an exceptional level of honesty and integrity. As an

applicant to the Nursing program at CSU Stanislaus you are responsible for the accuracy of your

application. Your signature below verifies that the information contained in this application is true

and accurate to the best of your knowledge. Falsifying or knowingly providing inaccurate

information is grounds for disqualification and/or dismissal from the nursing program.

I certify that the foregoing statements on this application are true, complete, and accurate:

Print Name:

Signature of Applicant: _ Date:

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STATISTICAL DATA FORM

The following information will be used for accreditation and the State Board of Registered Nursing statistical reports only. The data is confidential. It is unlawful to discriminate against you on the basis of this information.

Full Legal Name Semester Application is for Date of Birth

Fall Year Spring Year

GENDER:

RACE / ETHNICITY:

Male Female

(Please select only one)

BLACK: ………. African origin; not of Hispanic origin

ASIAN: ………….……….. Far Eastern, Southeast Asian, or Indian Origin

Chinese Japanese Korean Vietnamese Asian Indian Cambodian Laotian Other

PACIFIC ISLANDER: …… Hawaiian Islands or Pacific Island origin

Hawaiian Guamanian/Chamorro Samoan Other HISPANIC: ………...Spanish/Latin-American/Latino

Cuban Mexican Mexican-American/Chicano Puerto Rican Other

CAUCASIAN

AMERICAN INDIAN: ….Indian origin Native to the Americas with cultural identification Aleut Eskimo Native American: Tribe/Nation

Other

FILIPINO

OTHER NON-WHITE DECLINE TO STATE

CHECK THE PROGRAM FOR WHICH YOU HAVE APPLIED: (select only one) ASBSN Pre-Licensure

LVN to BSN RN to BSN

HOW DID YOU LEARN OF OUR PROGRAM?

CSU, Stanislaus Outreach Office Advertising (source) Colleague, Friend, Alumni or Relative CSU School of Nursing

Hospital Another college’s nursing program

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