DEMOGRAPHIC INFORMATION

(1)

AKRON SCHOOL OF PRACTICAL NURSING STUDENT APPLICATION

APPLICATION FOR FULL-TIME PROGRAMS

PROGRAM OF INTEREST – FULL TIME DAY LPN PROGRAM

August 2013 – June 2014 ______ January 2014 – January 2015 ______ August 2014 – June 2015 ______

STNA PROGRAM

March 2013 ________ July 2013 _________ October 2013 _________

DEMOGRAPHIC INFORMATION

NAME SOCIAL SECURITY #

Last First Middle

E-MAIL BIRTH DATE

ADDRESS

Number Street City State Zip

CELL PHONE NO. HOME PHONE NO.

HAVE YOU PREVIOUSLY APPLIED FOR ADMISSION TO THIS SCHOOL? ______

IF SO, WHEN? __________________________________________

HAVE YOU PREVIOUSLY ATTENDED A SCHOOL OF NURSING? ______

IF SO, WHERE & WHEN? __________________________________________

WERE YOU REFERRED TO US BY A CURRENT OR FORMER STUDENT?

IF SO, WHO CAN WE THANK FOR THE REFERRAL?

IF YOU WERE NOT REFERRED TO US, HOW DID YOU LEARN OF OUR PROGRAM?

(2)

EDUCATIONAL BACKGROUND

NAME OF HIGH SCHOOL CITY STATE

WHAT WAS YOUR LAST NAME AT THE

TIME YOU ATTENDED HIGH SCHOOL GPA

DATE OF HS GRADUATION

IF YOU DID NOT GRADUATE HS, DATE OF GED COMPLETION

NAME OF COLLEGE/SCHOOL ATTENDED SINCE GRADUATING HIGH SCHOOL OR RECEIVING YOUR GED:

SCHOOL YEARS ATTENDED

(FROM/TO)

DEGREE OR CERTIFICATE

EARNED

DID YOU GRADUATE

(Y/N)?

NOTE: YOU MUST SUBMIT AN OFFICIAL TRANSCRIPT FROM ANY SCHOOL YOU WISH TO BE EVALUATED FOR TRANSFER CREDIT.

WORK EXPERIENCE

PLEASE LIST ALL WORK EXPERIENCES, WITH THE MOST CURRENT INFORMATION FIRST TYPE OF

WORK

COMPANY NAME

NAME OF SUPERVISOR

DATES EMPLOYED

REASON FOR LEAVING

ATTENDANCE (GOOD, FAIR,

OR POOR)

(3)

BOARD OF NURSING COMPLIANCE QUESTIONNAIRE

Please circle a respose to each question below. Circling “Yes” does not automatically disqualify you from admission.

1. Have you EVER been convicted of, found guilty of, pled guilty to, pled no contest to, pled not guilty by reason of insanity to, entered an Alford plea, received treatment or intervention in lieu of conviction, or received diversion for any of the following crimes? This includes crimes that have been expunged IF there is a direct and substantial relationship to nursing practice. Please answer BOTH questions a and b.

a. A felony in Ohio, another state, commonwealth, territory, province, or country? Yes No b. A misdemeanor in Ohio, another state, commonwealth, territory, province, or country? (This does

not include traffic violations unless they are DUI/OVI)

Yes No 2. Have you ever been found to be mentally ill or mentally incompetent by a probate court? Yes No 3. Has any board, bureau, department, agency or other body, including those in Ohio, other than this

Board, in any way limited, restricted, suspended, or revoked any professional license, certificate, or registration granted to you; placed you on probation; or imposed a fine, censure, or reprimand against you? Have you ever voluntarily surrendered, resigned, or otherwise forfeited any professional license, certificate, or registration?

Yes No

4. Have you ever, for any reason, been denied an application, issuance, or renewal for licensure, certification, registration, or the privilege of taking an examination in any state (including Ohio), commonwealth, territory, province, or country?

Yes No

5. Have you ever entered into an agreement of any kind, whether oral or written, with respect to a professional license, certificate, or registration in lieu of or in order to avoid formal disciplinary action, with any board, bureau, department, agency, or other body, including those in Ohio, other than this Board?

Yes No

6. Have you been notified of any current investigation of you, or have you ever been notified of any formal charges, allegations, or complaints filed against you by any board, bureau, department, agency, or other body, including those in Ohio, other than this board, with respect to a professional license, certificate, or registration?

Yes No

7. Have you ever been diagnosed as having, or have you been treated for, pedophilia, exhibitionism, or voyeurism?

Yes No 8. Within the last five years, have you been diagnosed with or have you been treated for bipolar

disorder, schizophrenia, paranoia, or any other psychotic disorder?

Yes No 9. Have you, since attaining the age of eighteen or within the last five years, whichever period is

shorter, been admitted to a hospital or other facility for the treatment of bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder?

Yes No

10. Are you currently engaged in the illegal use of chemical substances or controlled substances, now or during the past two years?

Yes No a. If you answered “Yes” to question 10, are you currently participating in a supervised

rehabilitation program or professional assistance program which monitors you in order to assure that you are not illegally using chemical substances or controlled substances?

If you answered “Yes”, you are required to provide a written explanation.

If you are participating in a monitoring program, you are required to cause the respective program to provide information detailing your participation in and compliance with the program.

Yes No N/A

11. Have you been notified of any proceeding to determine whether you may be subject to listing on the Sexual Civil Child Abuse Registry established by the Ohio attorney general pursuant to section 3797.08 of the Revised Code, and/or are you listed on that registry?

Yes No

If you circled “Yes” to any question – please explain on the reverse side. Your application will not be considered complete if you fail to explain any “Yes” question.

(4)

If you entered “Yes” to any question on the reverse side, please complete the following questions.

1. Question you circle “Yes”:

Please explain:

If the question relates to a criminal offense, please provide the ORC number:

What was the final disposition?

*You will be required to submit an official journal entry from the court system before an acceptance letter can be offered.

2. Question you circled “Yes”:

Please explain:

3. Question you circled “Yes”:

Please explain:

(5)

WRITTEN RESPONSE ON PERSONAL COMMITMENT AND GROWTH

Your responses to these questions will be reviewed by the Admissions Committee. Please answer on a separate sheet of paper and attach to this application. Please TYPE your responses.

1. How did you hear about ASPN? Why did you choose our program over other programs?

2. Why are you an ideal candidate for our program?

3. Why does a career in nursing appeal to you?

4. How do you expect to juggle school and other adult responsibilities?

5. What do you think will be your greatest challenge with school? What will you do to help ensure you will be successful?

You will be scored based on your thoughtfulness, completeness, and grammar. You will not be scored on the specific details you share (i.e., there are no “right” or “wrong” answers). Documentation is an important task within the world of Nursing. Please do not rush through this section of the application.

(6)

APPLICANT ATTESTATION

I certify that the information I have given on this application is true and complete. I authorize investigation of all statements contained in this application and understand that by giving any false information, including that given at the time of the physical examination, is sufficient reason for dismissal from the program, if accepted. I understand that I will be expected to abide by all rules and regulations of the Akron School of Practical Nursing if accepted.

____________________________________________ ___________________________________

Signature of Applicant Date

Please check to see that you have answered all questions listed on the back of this page. Then mail this application with the required non-refundable application fee of $40.00 to:

Akron School of Practical Nursing 1532 Peckham Street

Akron, OH 44320 (330) 873-3355 (330) 873-3359 FAX

You will receive a notice that we have received your application, along with the next steps if your application is completed in full. You should receive this confirmation within three weeks of submission. Thank you!

The Akron Board of Education does not unlawfully discriminate on the basis of sex, age, race, color, religion, disability, political affiliation or national origin in employment or in its educational program and activities.