PRACTICAL NURSING APPLICATION FOR ADMISSION
Full Legal Name
Last First Middle Maiden Address
City, State, Zip
Primary Phone ( ) Secondary Phone ( )
E-Mail Address __________________________________________________________
Social Security Number Date of Birth
Place of Birth (City, State, County, Country) Citizenship
United States
Other immigration status (attach copy of documentation)
Alien lawfully admitted for permanent residency in the United States (attach copy of front and back of alien registration card)Name of High school: City & State:
Date of Graduation: GED Testing Location: Date Passed:
Post Secondary, technical schools, colleges or universities and/or Nursing Programs* attended: If you have previously attended another nursing school (not pre-nursing course) please call the coordinator for information about required paperwork.
Institution Address Reason for leaving
The Portage Lakes Joint Vocational School District is an equal opportunity educational institution. Employment and educational programs are offered without regard to race, color, religion, national origin, gender, disability, military status, ancestry, age, genetic information or any other legally protected characteristic. The district prohibits harassment of individuals in any form. Concerns of possible discrimination or harassment should be referred to Mr. Michael Kaschak, Compliance Coordinator, at 330-896-8200.
I understand that making application for admission to the Portage Lakes Career Center-W. Howard Nicol School of Practical Nursing places no obligation upon me or the school with regard to my admission until such time as I might be accepted for admission.
I certify that all statements made on this page of this application are true.
Signature Date
Application Instructions: 1.Complete the entire application in ink (Please print or type).
2. Attach the deposit of $100 payable to Portage Lakes Career Center.
3. Return the application And deposit to:
P.L.C.C.-PN Program 4401 Shriver Rd Uniontown, OH 44685 4. If you have questions, call: 330-896-8105.
5. Schedule your pre-admission WorkKeys assessment by calling Kim Robinson at: 330-896-8123.
6. Application does not guarantee admission.
Portage Lakes Career Center
W. Howard Nicol School of Practical Nursing
Background Information
The following is information that is required by the school, its clinical sites and/or the Ohio Board of Nursing for licensure. It
is our desire to make you aware of this information prior to making any financial commitment to the program. If you respond
“yes” to any of these questions, need clarification, or have concerns about these questions, please contact the program’s
coordinator.
1. Have you ever been convicted of, found guilty of, pled guilty to, pled guilty to by reason of insanity, entered an
Alford plea, received treatment or intervention in lieu of conviction, or received diversion, for any reason, of the following
crimes (this includes crimes that have been expunged or sealed).
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?
YES NO
(This does not include traffic violations unless they are DUI/OVI).
If you answered yes to either question, you are required to provide the school with a written
explanation of the events including the date, county, and state in which the events occurred.
Attach a separate sheet to the application. Also submit a certified copy of the indictment, plea
and journal entry from the appropriate court for each offense. A copy of the court docket or
case summary does not meet this requirement.
2. Have you ever been found to be mentally ill or mentally incompetent by a probate court?
YES NO
If you answered yes, you are required to provide the school with a written explanation of
the events including the date, county, and state in which the events occurred. Attach a
separate sheet to the application.
3. Has any board, bureau, department, agency or other public body, including those in Ohio, in anyway
limited, restricted, suspended, or revoked any professional licensure or certificate granted to you,
placed you on probation, imposed a fine, censure, or reprimand against you?
YES NO
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 license/certification
or privilege of taking 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 a respect to a
professional license or certification in lieu of or in order to avoid formal disciplinary action with
any board, bureau, department, agency, or other public body, including those in Ohio?
YES NO
6. Have you ever been notified of any current investigation of you or have you been notified of
any formal charges, allegations, or complaints filed against you by any board, bureau,
department, agency, or other public body, including those in Ohio?
YES NO
7. Have you ever been diagnosed as having or have you been treated for pedophilia, exhibitionism,
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, which ever period is
shorter, been admitted to a hospital or 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?
YES NO
For the purposes of this question “currently” does not mean the day of or even weeks or months
preceding the completion of this application. Rather, it means within the last two years or recently
enough so that the use of drugs may have an ongoing impact on one’s functioning in the delivery of
safe patient care. Illegal use of chemical substances or controlled substances means the use of
chemical substances or controlled substance obtained illegally (for example; marijuana, heroin,
cocaine, or methamphetamine) as well as the use of controlled substances which are not obtained
with a valid prescription or not taken in the accordance with the direction of a licensed healthcare
provider.
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?
YES NO
If you answered yes, you are required to provide a written explanation.
If you are participating in a monitoring program, you are required to have the program
provide information detailing your participation in and compliance with the program.
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 Ohio Revised Code and/or are you listed on that registry?
YES NO
Please review the Criminal Record Policy enclosed in this packet.
If any question is unanswered the application will be returned to you for completion.
I certify that all statements made on this page are true.
____________________________________________
__________________
PORTAGE LAKES CAREER CENTER
W. HOWARD NICOL SCHOOL OF PRACTICAL NURSING
STUDENT HANDBOOK
DRUG AND ALCOHOL POLICY
All students will undergo a drug screen by urine test prior to or at the time that the program begins. Students must submit a urine sample within two (2) hours of the time requested. This test will be conducted by an independent agency contracted with the school. All results will be confidentially reported to and become property of the school. Blood alcohol levels or breathalyzer tests may also be required. Results that show dilute urine will require a retest at a date and time scheduled by the school.
Portage Lakes Career Center – W. Howard Nicol School of Practical Nursing has a zero tolerance policy regarding the use of illegal drugs and the abuse of alcohol and/or prescription drugs. Students are required to be free from the use and appearance of use of alcohol and drugs while in class, lab, and clinical experiences. The safety of any client, student, and staff require that anyone using illegal substances be removed from the program.
Random drug screens will be conducted with or without cause during the course of the program. The faculty has the right and responsibility to remove students from the classroom and/or clinical site if the student’s behavior presents a concern for client safety. Students who have been removed from the educational setting will be required to have an immediate drug and alcohol screen done at the facility of the school’s choice. Students will be advised against operating a motor vehicle. In the interest of safety, local authorities will be notified if students do so.
Students who have a positive drug screen for prescription drugs are required to submit the prescription bottle to the Coordinator of the program at the beginning of the next school day. Failure to submit the requested prescription will result in a recommendation for immediate dismissal from the program.
Students who test positive for illegal substances or legal substances for which they have no prescription will be recommended for immediate termination from the program. Students terminated for the reasons noted above forfeit readmission to the program.
Students are required to disclose any history of alcohol and/or drug abuse/addiction to the Coordinator prior to beginning the program.
Possession, distribution or sale of alcohol or any illegal, illegally obtained or prescription drug at the school or at any affiliation, observation site, or school function will result in a recommendation for immediate dismissal.
The cost of all drug and alcohol screenings, assessment and evaluations, counseling and or treatment is the responsibility of the student.
The student will be advised to see a chemical assessment counselor, have an assessment done, and follow the recommendations of the counselor.
The applicant/student who currently, or within the past two (2) years, is participating in a program monitoring for drug and/or alcohol use, is in rehabilitation, treatment or a professional assistance program must provide the Coordinator with detailed information detailing participation and compliance with the program.
My signature indicates that I have read and understand this policy.
PORTAGE LAKES CAREER CENTER
W. HOWARD NICOL SCHOOL OF PRACTICAL NURSING CRIMINAL RECORD POLICY
This policy serves to protect the clients, students and staff of Portage Lakes Career Center and Clinical Affiliation sites. The safety and well- being of the patients, for whom care is provided, is our primary consideration. All students will have an Ohio and FBI criminal records check done prior to or at the start of the program. Fingerprinting for the criminal records check will be done at Portage Lakes Career Center. The Ohio Bureau of Criminal Identification and Investigation will conduct the criminal records check. The results of the records check will be sent to the Career Center and become the property thereof.
Students are not permitted to participate in clinical experiences until their report is received. Students may be denied access to clinical sites due to criminal record(s).
Students who have failed to disclose any criminal records on their application will be immediately terminated from the program for falsification of the application. Students who have a criminal charge occurring between the time of application and the first day of attendance must disclose the charge immediately.
The Ohio Board of Nursing must, by law, refuse licensure to a person whose record indicates that the person has pled guilty to, been convicted of or has had a judicial finding of guilt for committing Aggravated Murder, Murder, Voluntary Manslaughter, Felonious Assault, Kidnapping, Rape, Sexual Battery, Gross Sexual Imposition, Aggravated Burglary, or a substantially similar law of another state or country. For this reason a person who has such a criminal record will not be admitted to the program.
Persons having other criminal records may be, by law, barred from employment in pediatric and adult care facilities. The clinical sites with whom the school is contracted require that the students meet the same criteria as employees. The crimes included are:
Records with a pending disposition or outstanding warrant, three or more misdemeanor convictions, two or more DUI convictions or misdemeanor marijuana convictions, failure to appear in court, all convictions involving: violence, weapons, controlled substances, sexual activity, theft, dishonesty, burglary, and crimes against children. In addition, felony convictions for the following crimes: forgery, conspiracy to commit arson, aggravated assault, robbery, welfare or medical fraud, falsification to law enforcement, passing bad checks (more than one), possession of a concealed firearm, aiding a prisoners escape, patient abuse or neglect, insurance fraud, receiving stolen property, drug abuse, vehicular homicide, misuse of credit cards, contributing to the delinquency of a minor, and extortion.
Dispositions of not guilty, waiver by clerk or magistrate, adjudication withheld, or dismissed are permissible. Traffic violations are permissible.
Conviction of any of the following charges will exclude students from enrolling at Portage Lakes Career Center:
Abduction Improperly Furnishing Firearms to a Minor
Aggravated Arson Intimidation of Public Servant or Witness
Aggravated Burglary Kidnapping
Aggravated Murder Loitering to Engage in Prostitution
Child Enticement Murder
Child Stealing Pandering Obscenity Involving a Minor Compelling Prostitution Permitting Child Abuse
Corruption of a Minor Placing Harmful Objects in Food or Confection Counterfeit Drug Offenses Possession of Hoax Weapon of Mass Destruction Deception to Obtain Dangerous Drug Promoting Prostitution
Deception to Obtain Matter Harmful to Juveniles Prostitution Dissemination or Displaying Matter Harmful to Juveniles Rape
Endangering Children Reckless Homicide
Felonious Assault Retaliation Against Public Servant or Witness Felonious Sexual Penetration Riot
Funding of Drug or Marijuana Trafficking Robbery
Gross Sexual Imposition Sexual Battery
Illegal Conveyance or Possession of Deadly Weapon or Sexual Imposition
Counterfeit Firearm into a School Safety Zone Soliciting or Supporting Terrorism Illegal Dispensing of Drug Samples Trafficking in Drugs
Illegal Manufacture of Drugs or Cultivation of Marijuana Trafficking in Harmful Intoxicants Illegal Use of Minor in Nudity-Oriented Material or Performance Unlawful Possession of Explosives Improperly Discharging a Firearm At or Into a School Voluntary Manslaughter
Applicants with any other criminal records are required to submit certified copies of the Indictment, Plea and Journal Entry for each offense with their application. The applicant will be counseled regarding admission, clinical site availability, potential for employment and licensure.
Students will be fingerprinted a second time six to eight weeks prior to graduation. The results of the BCI & FBI criminal background check will be sent to the Ohio Board of Nursing and the school. Students with criminal records will be subject to the above stated policy.
Criminal Offenses, in addition to those listed above that Preclude Admission to the Practical Nursing Program Reckless Homicide, Abduction, Child Stealing, Child Enticement Disseminating, and Displaying Matter Harmful to Juveniles
Dispositions of not guilty, waiver by clerk or magistrate, adjudication withheld or dismissed are permissible. Traffic violations are permissible.
My signature indicates that I have read and understand this policy.
Signature: _________________________________________________ Date: ______________________
