POPLAR BLUFF TECHNICAL
CAREER CENTER
PRACTICAL NURSE PROGRAM
APPLICATION PACKET
CLASS #72
2014-2015
Full Approval Status by the Missouri State Board of Nursing
Approved by the
Missouri State Department of Education
Nationally Accredited by North Central Association
Table of Contents
Page
General Information
1
Application Process (includes Items # 1-7)
1
Selection
3
Informational Session
3
Financial Aid
3
Advanced Placement
3
Admission
3
English as Second Language
3
Tuition
4
Estimated Program Cost 4
Nurse Practice Act Licensure Information
4
NCLEX Eligibility & Requirements
5
Refunds of Tuition and Fees
6
Required Minimal Functional Abilities
6
Admission Requirements/Criteria
8
Curriculum Sequence
9
Request for Accommodations
11
Admission Rating System
12
Confidential Release Waiver, Agreement &
13
Criminal Background Check Authorization
TO:
Applicants of the Poplar Bluff R-1 Practical Nursing Program
FROM:
Jolon Vaughn, MSN, RN-Coordinator of the Practical Nurse Program
I am very pleased with your interest in the Poplar Bluff R-1 Practical Nurse Program. This application packet
contains forms and information that you will need to apply for our next class which begins July 2014.
It is important to read the entire packet thoroughly. This information has been provided for the purpose of
completing the application process correctly and expediently. When printing this document off of the
computer, please print it as a one-sided document. Printing this packet out as a two-sided document (or front
& back) may cause it to print out incorrectly.
The Application Process Consists of the Following Components and Criteria:
***Deadline for all items listed below is March 1st, 2014, NOON.***
1. Application Form: Please complete the form as instructed (located on page 14).
2. Application Processing/Testing Fee:
$50.00 non-refundable fee
You may make money orders payable to: Poplar Bluff R-1 Schools
In order to ensure application processing, please pay by cash or money order in the main office of the
nursing school at 3203 Oak Grove Rd., Poplar Bluff, MO 63901. (Do not mail cash.)
3. Official High School Transcript - A copy of an official transcript from the high school from which
you graduated is required. This may be obtained by requesting your school to send the transcript to
our school. The transcript must have the school seal and/or signature of a school official. An official
transcript may be hand delivered by you only if it is in its original institutional envelope and the seal has
NOT been broken. Please have the school send the official transcript(s) to:
Poplar Bluff TCC Practical Nurse Program
3203 Oak Grove Rd., Poplar Bluff, MO 63901
OR
GED –A copy of the GED scores and certificate must be obtained or an online transcript. You may find
information on obtaining your online transcript by going online to:
www.ged.mo.gov
College Transcripts- A copy of a transcript from a college may be an unofficial transcript and may be
hand-carried by the student to the school.
4.
Criminal Background Check (Caregiver Background Screening):
A.
You must sign the Criminal Background Check Authorization located on page 13
in this packet.
B.
Must provide copy of marriage license or a divorce decree; drivers license; birth certificate;
social security card; immunizations; and proof of address (utility bill)
5.
Personal/Professional Recommendation:
A.
Please list the complete names and current addresses of three (3) individuals in the appropriate
spaces on the application form. The names you put on the application must be who you give
recommendation forms to.
B.
If at all possible include past or present employers, supervisors, co-workers or someone who has
worked with you closely in the past two to three (2-3) years. This could include volunteer work,
service projects, Parent Teacher Organization, Boy/Girl Scouts, Counselor, etc.
C.
DO NOT list relatives, family physicians (unless work related).
D.
A recommendation form will be provided for the names you have listed in the application.
The person doing the recommendation will be asked to return the form directly to the school. All
three (3) references must be returned by February 27, 2014, by 12:00 Noon.
The mailing address for the recommendations to be returned is:
Poplar Bluff TCC, Practical Nurse Program
3203 Oak Grove Rd.
Poplar Bluff, MO 63901
E.
Please complete the enclosed confidential release waiver and return with your application.
F.
Please read the form and familiarize yourself with the aspects of your character the individual
will be remarking on. This is an important component of the selection process.
6.
Pre-Entrance Testing:
A:
The TEAS (Test of Essential Academic Skills), version V, is scheduled and administered at
the Poplar Bluff TCC, Practical Nurse Program, 3203 Oak Grove Rd., Poplar Bluff, MO after the
application has been completed and the application testing/fee has been paid. A written notice
will be mailed to you on or before March 3, 2014, indicating the date and time of your test. A
limited number of applicants will be scheduled for each test date.
B:
Scheduling/Rescheduling - You will be allowed to test once (1 time) during the application
process. The dates listed below have been scheduled for pre-entrance testing. You may
indicate two preferences for the scheduled test dates. However, priority will be given to the
applicant who submits all required information first. It is also your responsibility to reschedule
your test date if you are unable to make the date you selected or were assigned
The test dates are as follows:
March 8, 2014 Saturday
8am – 12 noon
March 11, 2014 Tuesday
1pm- 4pm
4:30pm to 8:30pm
March 12, 2014 Wednesday
8 am – 12 noon 1pm – 4 pm
The TEAS (Test of Essential Academic Skills) will consist of several sections including Reading,
Mathematics, Science and English & Language Usage. This will be a timed test. You may not bring
a calculator for the Math section.
The TEAS Online Practice Assessment and the TEAS Study Manual, version V, may be purchased from
ATI by going to
www.atitesting.com/onlinestore
or calling 1-800-667-7531.
7.
Selection - Applications will be reviewed and selection by the Admission Committee will primarily be
based on the TEAS score results with strong consideration given to references, and transcripts.
8.
Informational Session - In order for you to qualify for the informational meeting session with the nurse
director or designated individual, you must first meet the testing criteria as outlined above.
(Refer to Pre-Entrance Testing)
Once the test results are received in our office and the Admissions Committee has had the opportunity to
meet, you will be notified in writing or by phone of the interview dates and times. Once interviews are
completed, you will receive a letter in the mail of your admission status. Please review the admission
scoring sheet on page 12 before your interview.
Informational Meeting session date will be included in your acceptance letter. Attendance of
accepted individuals is required. If you are an alternate and wish to keep your place on the alternate
list, your attendance at the Informational Meeting is required. Please notify the nursing office as soon as
possible if there is an extenuating reason that would prevent you from attending.
During the session, information about the program will be given and test results discussed. An
explanation of the admission rating system utilized by the selection committee will be provided. At this
time, you have the opportunity to ask questions about the program, application process, admission rating
system, etc. Important program policies will also be reviewed with you. You will schedule an
appointment with the Financial Aid Advisor during this meeting.
9.
Financial Aid - For information regarding financial aid, please speak with Gina Duckett, Financial Aid
Secretary, in the Financial Aid Office at Poplar Bluff Technical Career Center, 3203 Oak Grove Rd.,
Poplar Bluff, MO or you may contact her by phone at (573) 785-2248. You will need to complete the
FAFSA online prior to April 1, in order to have documentation in place before classes begin. That
web address is
www.fafsa.ed.gov
. The school code for FAFSA is 013683. See PBTCC Postsecondary
Catalog Page 11 for Financial Responsibilities.
10.
Advanced Placement – Poplar Bluff R-1, Practical Nurse Program does not allow advanced placement
of students. This is a requirement set forth by the Missouri State Board of Nursing regarding schools of
practical nursing. All students, regardless of academic history, are required to attend the nursing
program in its entirety.
11.
Admission - No student will be admitted after five (5) days have passed since the established beginning
date of classes for the academic year.
12.
English as Second Language – English as Second Language students are required to meet the same
criteria as any other student.
13.
Tuition – will be In-District $9487.00; Out-of-District & $9,961.00; plus program fees of $2,970. This
amount may be subject to change. The tuition includes fees for textbooks, uniforms, state board testing,
lab supplies, professional liability insurance, name badge, stethoscope, standardized testing for
NCLEX-PN readiness, and graduation pin.
ESTIMATED COSTS
PRACTICAL NURSING PROGRAM
Tuition ...
In- District 9,487.00
Out-of-District 9,961.00
Program Fees
2,970.00
Estimated Total In-District $12,457.00
Estimated Total Out-Of-District $12,931.00
*Tuition subject to change at any time upon approval/recommendation of the Poplar Bluff R-1 School Board.*
15.
Nurse Practice Act
335.066. Denial, revocation, or suspension of license, grounds for, civil immunity for providing information.
1. The board may refuse to issue any certificate of registration or authority, permit or license required pursuant
to sections 335.011 to 335.096 for one or any combination of causes stated in subsection 2 of this section.
The board shall notify the applicant in writing of the reasons for the refusal and shall advise the applicant of
his or her right to file a complaint with the administrative hearing commission as provided by chapter 621,
RSMo.
2. The board may cause a complaint to be filed with the administrative hearing commission as provided by
chapter 621, RSMo, against any holder of any certificate of registration or authority, permit or license
required by sections 335.011 to 335.096 or any person who has failed to renew or has surrendered his or her
certificate of registration or authority, permit or license for any one or any combination of the following
causes:
(1) Use or unlawful possession of any controlled substance, as defined in chapter 195, RSMo, or alcoholic
beverage to an extent that such use impairs a person's ability to perform the work of any profession licensed
or regulated by sections 335.011 to 335.096;
(2) The person has been finally adjudicated and found guilty, or entered a plea of guilty or nolo contendere,
in a criminal prosecution pursuant to the laws of any state or of the United States, for any offense reasonably
related to the qualifications, functions or duties of any profession licensed or regulated pursuant to sections
335.011 to 335.096, for any offense an essential element of which is fraud, dishonesty or an act of violence,
or for any offense involving moral turpitude, whether or not sentence is imposed;
(3) Use of fraud, deception, misrepresentation or bribery in securing any certificate of registration or
authority, permit or license issued pursuant to sections 335.011 to 335.096 or in obtaining permission to take
any examination given or required pursuant to sections 335.011 to 335.096;
(4) Obtaining or attempting to obtain any fee, charge, tuition or other compensation by fraud, deception or
misrepresentation;
(5) Incompetency, misconduct, gross negligence, fraud, misrepresentation or dishonesty in the performance
of the functions or duties of any profession licensed or regulated by sections 335.011 to 335.096;
(6) Violation of, or assisting or enabling any person to violate, any provision of sections 335.011 to 335.096,
or of any lawful rule or regulation adopted pursuant to sections 335.011 to 335.096;
(7) Impersonation of any person holding a certificate of registration or authority, permit or license or
allowing any person to use his or her certificate of registration or authority, permit, license or diploma from
any school;
(8) Disciplinary action against the holder of a license or other right to practice any profession regulated by
sections 335.011 to 335.096 granted by another state, territory, federal agency or country upon grounds for
which revocation or suspension is authorized in this state;
(9) A person is finally adjudged insane or incompetent by a court of competent jurisdiction;
4
(10) Assisting or enabling any person to practice or offer to practice any profession licensed or regulated by
sections 335.011 to 335.096 who is not registered and currently eligible to practice pursuant to sections
335.011 to 335.096;
(11) Issuance of a certificate of registration or authority, permit or license based upon a material mistake of
fact;
(12) Violation of any professional trust or confidence;
(13) Use of any advertisement or solicitation which is false, misleading or deceptive to the general public or
persons to whom the advertisement or solicitation is primarily directed;
(14) Violation of the drug laws or rules and regulations of this state, any other state or the federal government;
(15) Placement on an employee disqualification list or other related restriction or finding pertaining to
employment within a health-related profession issued by any state or federal government or agency following
final disposition by such state or federal government or agency.
3. After the filing of such complaint, the proceedings shall be conducted in accordance with the provisions of
chapter 621, RSMo. Upon a finding by the administrative hearing commission that the grounds, provided in
subsection 2 of this section, for disciplinary action are met, the board may, singly or in combination, censure
or place the person named in the complaint on probation on such terms and conditions as the board deems
appropriate for a period not to exceed five years, or may suspend, for a period not to exceed three years, or
revoke the license, certificate, or permit.
4. An individual whose license has been revoked shall wait one year from the date of revocation to apply for
relicensure. Relicensure shall be at the discretion of the board after compliance with all the requirements of
sections 335.011 to 335.096 relative to the licensing of an applicant for the first time.
5. The board may notify the proper licensing authority of any other state concerning the final disciplinary action
determined by the board on a license in which the person whose license was suspended or revoked was also
licensed of the suspension or revocation.
6. Any person, organization, association or corporation who reports or provides information to the board of
nursing pursuant to the provisions of sections 335.011 to 335.259* and who does so in good faith shall not be
subject to an action for civil damages as a result thereof.
(L. 1975 S.B. 108 § 12, A.L. 1981 S.B. 16, A.L. 1995 S.B. 452, A.L. 1999 H.B. 343)
*Section 335.259 was repealed by S.B. 52 § A, 1993.
16.
Completion of the program and eligibility to take NCLEX for licensure.
Graduates of the Practical Nurse Program are eligible to apply to the Missouri State Board of Nursing for
permission to take the NCLEX-PN Examination upon completion of the program. Completion of the program
does not guarantee eligibility to take the NCLEX-PN Examination. This is determined by the State Board of
Nursing.
17. Qualifications for Applying for a Nursing License
An applicant for license to practice as a licensed practical nurse shall:
1. Submit a written application on the forms to the State Board of Nursing furnished to the student
(done after admittance to the program).
2. Be of good moral character. (Fingerprinting & Criminal background check is required.)
3. Have high school diploma or passed equivalency exam (G.E.D.).
4. Have successfully completed a program at an accredited school of nursing.
5. Have completed a course approved by the board on the role of the practical nurse.
6. Shall submit evidence of proficiency in the English language if applicant is from
a non-English speaking country.
7. Be approved by the State Board of Nursing.
8. Be required to pass the State Board of Nursing Examination (NCLEX-PN).
18. Refund Policy for Financial Aid Recipients
Students who have received federal financial aid funds are required to earn these funds by attending classes
through at least 60% of the period of enrollment. Students who fail to meet this guideline will be required to
repay all or a portion of their financial aid.
This policy, established by the U.S. Department of Education through the Higher Education Act of 1965, affects
students who have received assistance through the following federal financial aid programs:
Pell Grant
Stafford Subsidized and Unsubsidized Loans
Attendance information is collected on a daily basis. If you are not attending classes it is important to officially
withdraw to determine the official withdrawal date. The official withdrawal date determines the amount you may
be required to repay the federal government for financial aid received which was intended to finance educational
costs while you are attending school.
Satisfactory Academic Progress for Financial Aid Purposes
To maintain eligibility for financial aid, a student must meet Satisfactory Academic Progress: maintain a “C”
average in each course. Failure to meet Satisfactory Academic Progress may result in being placed on Financial
Aid Warning or Probation. Failure to return to Satisfactory Academic Progress after being placed on Warning or
Probation status could cause a disruption in a student’s eligibility to receive Title IV Financial Aid funding.
Please see Gina Duckett in regards to Financial Aid questions
19.
Required minimal functional ability categories and representative activities/attributes:
a.
Gross Motor Skills
1.
Move within confined spaces
2.
Sit and maintain balance
3.
Stand and maintain balance
4.
Reach above shoulders (e.g., IV poles)
5.
Reach below waist (e.g., plug electrical appliance into wall outlets)
b.
Fine Motor Skills
1.
Pick up objects with hands
2.
Grasp small objects with hands (e.g., IV tubing, pencil)
3.
Write with pen or pencil
4.
Key/type (e.g., use a computer)
5.
Pinch/pick or otherwise work with fingers (e.g., manipulate a syringe)
6.
Twist (e.g., turn object/knobs using hands)
7.
Squeeze with finger (e.g., eye dropper)
c.
Physical Endurance
1.
Stand (e.g., at client side during surgical or therapeutic procedure)
2.
Sustain repetitive movements (e.g., CPR)
3.
Maintain physical tolerance (e.g., work entire shift)
d.
Physical Strength
1.
Push and pull 25 pounds (e.g., position clients)
2.
Support 25 pounds of weight (e.g., ambulate client)
3.
Lift 25 pounds (e.g., pick up a child, transfer client)
4.
Move light objects weighing up to 10 pounds (e.g., IV poles)
5.
Move heavy objects weighing from 11 to 50 pounds
6.
Defend self against combative client
7.
Carry equipment/supplies
8.
Use upper body strength (e.g., perform CPR, physically restrain a client)
9.
Squeeze with hands (e.g., operate fire extinguisher)
e.
Mobility
1.
Twist
2.
Bend
3.
Stoop/squat
4.
Move quickly (e.g., response to an emergency)
5.
Climb (e.g., ladders/stools/stairs)
6.
Walk
f.
Hearing
1.
Hear normal speaking level sounds (e.g., person-to-person report)
2.
Hear faint voices
3.
Hear faint body sounds (e.g., blood pressure sounds, assess placement of tubes)
4.
Hear in situations when not able to see lips (e.g., when masks are used)
5.
Hear auditory alarms (e.g., monitors, fire alarms, call bells)
g.
Visual
1.
See objects up to 20 inches away (e.g., information on a computer screen, skin conditions)
2.
See objects up to 20 feet away (e.g., client in a room)
3.
See objects more than 20 feet away (e.g., client at end of hall)
4.
Use depth perception
5.
Use peripheral vision
6.
Distinguish color (e.g., color codes on supplies, charts, bed)
7.
Distinguish color intensity (e.g., flushed skin, skin paleness)
h.
Tactile
1.
Feel vibrations (e.g., palpate pulses)
2.
Detect temperature (e.g., skin, solutions)
3.
Feel differences in surface characteristics (e.g., skin turgor, rashes)
4.
Feel differences in sizes, shapes (e.g., palpate vein, identify body landmarks)
5.
Detect environmental temperature (e.g., check for drafts)
i.
Smell
a.
Detect odors from client (e.g., foul smelling drainage, alcohol, etc.)
b.
Detect smoke
c.
Detect gases or noxious smells
j.
Reading
a.
Read and understand written documents (e.g., policies, protocols)
k.
Arithmetic Competence
1.
Read and understand columns of writing (e.g., flow sheet, charts)
2.
Read digital displays
3.
Read graphic printouts (e.g., EKG)
4.
Calibrate equipment
5.
Convert numbers to and/or from the Metric System
6.
Read graphs (e.g., vital sign sheets)
7.
Tell time
8.
Measure time (e.g., count duration of contractions, etc.)
9.
Count rates (e.g., drips/minute, pulse)
10.
Use measuring tools (e.g., thermometer)
11.
Read measurement marks (e.g., measurement tapes, scales, etc.)
12.
Add, subtract, multiply, and/or divide whole numbers
13.
Compute fractions (e.g., medication dosages)
14.
Use a calculator
15.
Write numbers in records
l.
Emotional Stability
1.
Establish therapeutic boundaries
2.
Provide client with emotional support
3.
Adapt to changing environmental/stress
4.
Deal with the unexpected (e.g., client going bad, crisis)
5.
Focus attention on task
6.
Monitor own emotions
7.
Perform multiple responsibilities concurrently
8.
Handle strong emotions (e.g., grief)
m.
Analytical Thinking
1.
Transfer knowledge from one situation to another
2.
Process information
3.
Evaluate outcomes
4.
Problem solve
5.
Prioritize tasks
6.
Use long term memory
7.
Use short term memory
n.
Critical Thinking
1.
Identify cause-effect relationships
2.
Plan/control activities for others
3.
Synthesize knowledge and skills
4.
Sequence information
o.
Interpersonal Skills
1.
Negotiate interpersonal conflict
2.
Respect differences in clients
3.
Establish rapport with clients
4.
Establish rapport with co-workers
p.
Communication Skills
1.
Teach (e.g., client/family about health care)
2.
Explain procedures
3.
Give oral reports (e.g., report on client’s condition to others)
4.
Interact with others (e.g., health care workers)
5.
Speak on the telephone
6.
Influence people
7.
Direct activities of others
8.
Convey information through writing (e.g., progress notes)
20.
Admission Requirements/Criteria:
a. Complete & sign application forms in application packet & submit by deadline.
b. Satisfactorily complete pre-entrance exam (TEAS-V test).
c. Provide high school diploma or GED transcripts(& college, if applicable).
d. Provide copy of marriage license or divorce decree: birth certificate; drivers license; social security; immunization
record; and proof of address (utility bill)
e. Provide three (3) written references using the forms provided.
f. Satisfactory completion of criminal background check.
CURRICULUM SEQUENCE
Semester I
Course Name
Course Hours
Personal and Vocational Concepts
38
Anatomy and Physiology
95
Nutrition
40
Geriatrics
35
Pharmacology I
48/49
Fundamentals of Nursing
150/141
Intravenous Therapy
40/8
Total Theory Hours for Level I = 446
Total Clinical Hours for Level I = 198
TOTAL Hours for Level I = 644
Semester II
Course Name
Course Hours
Mental Health Nursing
45/28
Pharmacology II
72
Medical/Surgical
150/104
Obstetrics
45/28
Pediatrics
50/28
Leadership and Management
38/56
Observation and Review/exit testing
30/42
Total Theory Hours for Level II - 430
Total Clinical Hours for Level II - 286
TOTAL Hours for Level II
- 716
TOTAL PROGRAM HOURS for Semester I & II
1360
Sequence of courses are subject to change
Poplar Bluff TCC
PRACTICAL NURSE PROGRAM
REQUEST FOR ACCOMMODATION
INTRODUCTION
If you have a physical or mental impairment that substantially limits a major life activity, you may be
eligible for accommodations in the testing process which will ensure that the test accurately reflects your
skills, knowledge and abilities. Attempts will be made to provide a reasonable accommodation which
will allow you to demonstrate your abilities. Attempts will allow you to demonstrate your abilities.
Notify us prior to the start of school if you need special accommodations so that we may prepare for
them.
UNDERLYING PRINCIPLES
Poplar Bluff TCC, Practical Nurse Program may approve appropriate exam modifications which are
psychometrically sound and safeguard the fairness and security of the testing process for all applicants.
The Americans and Disabilities Act has encouraged applicants of nursing programs to identify the
essential abilities needed by nurses to practice safely. The applicants of nursing programs must be
aware of the abilities required for safe nursing practice and of any personal limitations with respect to
these abilities. Applicants of the nursing program should either make or request the accommodations
needed to practice nursing safely.
DESCRIPTION OF ACCOMMODATIONS REQUEST REVIEW & APPROVAL PROCESS
All requests for exam modifications from applicants must be accompanied by the following:
A letter of diagnosis from an appropriate health professional. The diagnosis must include a detailed
rationale justifying why the requested accommodation is necessary and appropriate for the diagnosed
disability.
AND
A letter from the applicant requesting the accommodations and detailing the specific accommodations.
After the application and all documentation have been received, the program director, adult counselor and
vocational education director will review the request and inform the applicant of their decision.
STATEMENT
Only physical or mental impairments that substantially limit one or more major life activities are
disabilities subject to the protection of the Americans with Disabilities Act (ADA).
Almost everyone experiences some apprehension before taking an important examination. Careful
diagnosis is required to address the issue of what point “normal” anxiety constitutes a disability
protected under ADA.
“Test anxiety, anxiety or phobia” without precise diagnosis, may not constitute a disability within the meaning
of ADA for the threshold reason that such terms are not recognized physiological or psychological impairments
which substantially limits a major life activity.
For more information or request accommodations, please contact the Poplar Bluff TCC, Practical Nurse Program.
Poplar Bluff TCC
PRACTICAL NURSE PROGRAM
Admission Rating System
Applicant Name __________________________ Judge #____________ The following is the admission rating which will be utilized for rating each eligible applicant:
Possible Points Description of Rating Points
Received 0-4 Application Packet:
Completeness (2) & Legibility (2)
0-7 References:
Content of Recommendation (Max. of 2 pts each) Add 1 point for having all 3 recommendations 0-14 Interview: each item scored 0-2
Appropriately dressed: ____ Communication Skills: ____ Punctual:____ Problem Solving: ____ Attitude:____ Understanding Nursing:____ Sincerity in Pursing a Nursing Career: ____
0-25 TEAS Reading Score:
100% = 25 90-91% = 20 80-81% = 15 70-71% = 10 60-61%= 5 98-99% = 24 88-89% = 19 78-79% = 14 68-69% = 9 58-59%=4 96-97% = 23 86-87% = 18 76-77% = 13 66-67% = 8 56-57%=3 94-95% = 22 84-85% = 17 74-75% = 12 64-65% = 7 54-55%=2 92-93% = 21 82-83% = 16 72-73% = 11 62–63% = 6 52-53%=1 <51% = 0
0-20 TEAS Math Score
98-100% = 20 83-85% = 15 68-70% = 10 53-55% = 5 95-97% = 19 80-82% = 14 65-67% = 9 50-52% = 4 92-94% = 18 77-79% = 13 62-64% = 8 47-49% = 3 89-91% = 17 74-76% = 12 59-61% = 7 44-46% = 2 86-88% = 16 71-73% = 11 56-58% = 6 41–43% = 1 < 40% = 0 0-15 TEAS Science Score:
97-100% = 15 77-80% = 10 57-60% = 5 93-96% = 14 73-76% = 9 53-56% = 4 80-92% = 13 69-72% = 8 49-52% = 3 85-88% = 12 65-68% = 7 45-48% = 2
81-84% = 11 61-64% = 6 41-44% = 1 < 40% = 0 0-15 TEAS English Score:
97-100% = 15 77-80% = 10 57-60% = 5 93-96% = 14 73-76% = 9 53-56% = 4 80-92% = 13 69-72% = 8 49-52% = 3 85-88% = 12 65-68% = 7 45-48% = 2 81-84% = 11 61-64% = 6 41-44% = 1 < 40% = 0 Total Points = 100
Total Points Received ____/100
Confidential Release Waiver
Personal references are given assurance of confidentiality. For this reason we are requesting the following
waiver agreement be signed. This is necessary in order to comply with Federal Law PL93-380, regarding
confidential letters and statements of recommendations submitted by the references on your behalf.
Agreement
I, _____________________________________________ hereby waive my right to see the
personal/professional letters of reference from people I have listed as references on my application for
admission to Poplar Bluff TCC, Practical Nurse Program. I do give permission for the selection committee to
have full access to this confidential information during the admission process.
Criminal Background Check Authorization
I understand that my acceptance into the program is contingent upon meeting all admission requirements
including a satisfactory Criminal Background Screening.
__________________________________________
Signature
__________________________________________
Date
Poplar Bluff Technical Career Center
2013-2014
Application for Admission - Postsecondary Programs
3203 Oak Grove Road Poplar Bluff, MO 63901
573-785-2248 573-785-4168 (fax) 573-785-6867 School of Practical Nursing
573-785-6683 School of Cosmetology
www.poplarbluffschools.net
Return this completed application and the appropriate non-refundable application fee. Make check payable to PBTCC. The application fee covers the cost of admission examinations and background check. Applications are not processed or considered complete until both fee and application are received.
Completion of this application does not constitute admission to the program of study for which applicant is applying. Part 1
Personal Information Social Security No. _________/_________/____________
Name_________________________________________________________________________________________________________ Last First Middle Jr/Sr Maiden/Alias_____________________________________________________________________________________________________
Last First Middle Jr/Sr
Address __________________________________City ___________________________________State _______________ Zip ________ Telephone - Home: _______-_______-_________ Telephone – Cell _______-_______-_________ Business: ______-_______-_________ Email ______________________________________________-___ Date of Birth _______/_______/________
Does student use language other than English? ____ If so, what language: ______________________
Part 2
Program Choice
Clearly mark the desired program of study. Cosmetology Application fee $25
___ Cosmetology/Manicure August Class - Applications accepted March 1 through May 1.
___ Cosmetology/Manicure February Class - Applications accepted September 1 through November 1 ___ Cosmetology/Manicure Additional Hours - See program coordinator for application submission information.
___ Cosmetology Instructor Training - See program coordinator for application submission information. ___ Esthetician - Applications accepted September through October 1
___ Manicure - Applications accepted January 1 through March 1 Practical Nursing Application fee $50
Applications will be accepted December 1 through March 1. ___ Practical Nursing Program
Technology & Industry Application fee $25
Applications will be accepted March 1 until June 30. After June 30 applications will only be accepted for programs with available openings. ___ Automotive Collision Repair ___ Automotive Technology ___ Building Trades
___ Computer Maintenance Technology ___ Culinary Arts ___ Welding
___ Computer Graphics & Print Technology ___ Heating, Ventilation, Air Conditioning & Refrigeration (HVACR)
Emergency Information
In case of emergency, please notify:
Name___________________________________________________________ Relationship to Student _________________________________________ Address _________________________________________________________City, State, Zip ________________________________________________ Home/Cell Phone _________________________________________________ Work Phone __________________________________________________ List any medical conditions PBTCC staff may need to be aware of:
_____________________________________________________________________________________________________________________________ In the event of an emergency I authorize Poplar Bluff Technical Career Center personnel in charge to use their discretion regarding emergency procedures. Student Signature ___________________________________________________________________ Date _____________________________________
Part 4
Student Status Information
(the following information is optional)
Gender: ___ Male ___ Female Marital Status: ___ Single ___ Married ___ Divorced ___ Widow/Widower Ethnic Description:
___ Nonresident Alien ___ Asian ___ Black, Non-Hispanic ___ Hispanic ___ American Indian or Alaskan Native ___ White, Non-Hispanic ___ Pacific Islander ___ Two or More Races ___ Race/Ethnicity Unknown
___ other: _________________________
I am eligible for the A+ Scholarship: ___ Yes ___ No I have received a bachelor’s degree: ____ Yes ____ NO I am eligible and will receive funding from the following agency to pay educational expenses:
___ VA Benefits ___ Vocational Rehabilitation ___ WIA ___ TRA
___ Private Company – name of company _________________________________Other: ________________________________________
Please list the name, address and social security number of the person eligible to claim the tax credits associated with the payment of tuition and related fees:
Name: ______________________________________________________Social Security Number ____________________________ ____________________________________________________________________________________________________________ Address City Zip
Part 5
Education Information and Work Experience
Name of high school: ___________________________________________________________________________________________________________ City State
Graduated (year) __________ or Will Graduate (year) _________ GED (year) _____________ Certificate No. ______________________________ Official high school transcript or GED scores must be forwarded to PBTCC to fully complete admission process.
Other Education Beyond High School – Official post-secondary school transcript must be forwarded to PBTCC to fully complete admission process. Name of School City & State Degree/Certificate Dates of
Earned Attendance
_____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Have you ever experienced disciplinary or academic probation while attending a postsecondary institution of learning? ___________ If yes, please attach detailed explanation.
Work Experience
List work experiences related to your field of study. Include experiences you feel are of benefit to you in your chosen field of study. Employer Position/Job Title Years/Months Job Held
_____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________
Part 6
TO BE COMPLETED BY ALL APPLICANTS
Have you ever been arrested and convicted of a felony or misdemeanor? ________ If yes, please explain. _______________________________________ _____________________________________________________________________________________________________________________________ My signature below gives the Poplar Bluff Technical Career Center permission to perform a background check. I understand that my Social Security number and other personal data provided on this enrollment application may be used as an identifier. I further understand that the misrepresentation or omission of facts called for is cause for non admittance or dismissal from a Poplar Bluff Technical Career Center program of study.
_____________________________________________________________________________________________________________________________ Signature of Applicant Date
The Poplar Bluff Technical Career Center is an Equal Opportunity Employer and operates educational programs which do not discriminate on the basis of age, race, color, creed, religion, nationality origin, sex, marital status or handicap. The School district is prohibited from discriminatory practices by Title VI and Title VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act, Title II of Americans with Disabilities Act of 1990 and various state laws and regulations.
Return completed application, including the completed request for Criminal Record Check form and appropriate application fee to: Poplar Bluff Technical Career Center
3203 Oak Grove Road Poplar Bluff, MO 63901
Part 7
Functional Abilities Statement
The Poplar Bluff Technical Career Center programs require certain functional abilities a student must be able to do, possess, or be able to be taught in order to successfully complete the programs of study and perform in the chosen career fields. Refer to admissions section in the student catalog for the list of functional abilities required of students admitted into these programs.
I certify that I am physically and mentally able to perform the usual duties and functions associated with those of a nurse or cosmetologist and/or that I possess the capability to learn functional abilities as listed in student catalog in order to fulfill program requirements.
_____________________________________________________________________________________________________________________________ Signature of Applicant Date
APPLICATION CHECKLIST
Application - Date Received: __________
Application Fee Paid? ___yes ___no Amount Paid $________ ___High School Transcript or GED scores; ___
___College Transcript if applicable; ___Proof of Immunizations; ___Background Check Completed; Credentials Received:
__birth certificate __marriage license __driver’s license ___Proof of Residency: ___In-District ___Out-of-District
Poplar Bluff Technical Career Center Applicant Professional Reference Form
I, ___________________________________________________, DOB ___________________ have applied
for entrance to the Poplar Bluff Technical Career Center Cosmetology/Practical Nursing (circle one) program and hereby give my permission to release this information.
Name of person completing this form (please print): _________________________________________________Date _________________ How long have you known the applicant? ______________________________________________________________________________
In what capacity or relationship to the applicant are you completing this reference? _____________________________________________ (Mark all that apply)
Employer ________ Immediate Supervisor ________ Co-worker ________ Friend ________ Counselor _________ Pastor/Priest ________ Teacher ________ Health Care Provider _________ Relative ________
From your experience with this individual rate the following characteristics. Check one level of performance for each category.
EXCELLENT GOOD FAIR POOR
1. INTEGRITY __________ _______ ________ _________ 2. DEPENDABILITY __________ _______ ________ _________ 3. PUNCTUALITY __________ _______ ________ _________ 4. INITIATIVE __________ _______ ________ _________ 5. MORAL/ETHICAL CHARACTER __________ _______ ________ _________ 6. INDUSTRIOUSNESS __________ _______ ________ _________ 7. GROOMING __________ _______ ________ _________
Do you know of any physical or emotional handicap that would influence this individual’s performance in their chosen program of study? YES_____ NO ______ If so, please specify
________________________________________________________________________________________________________________
Would you employ this individual for a position which requires responsibility and stability? YES______ NO______ If no, please state reason: ________________________________________________________________________________________________________________
Would you recommend to the Poplar Bluff Practical Nurse Program that this person be admitted to the program? YES_______ NO______ Additional Comments: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
In order that the applicant may be considered for admission, please complete this form and return it to the school at your earliest
convenience. Please DO NOT GIVE it to the applicant. The applicant WILL NOT be seeing this completed form at any time and it will be
destroyed after the application process has been completed. All information will be kept confidential. Feel free to contact the school for
any further information.
________________________________________________________________________________________________________________ Signature of Person Completing Form ____________________________________
Address State Zip ____________________________________________________
School Address: Poplar Bluff Practical Nurse Program 3203 Oak Grove Road
Poplar Bluff, MO 63901 (573) 785-6867
Poplar Bluff Technical Career Center Applicant Professional Reference Form
I, ___________________________________________________, DOB ___________________ have applied
for entrance to the Poplar Bluff Technical Career Center Cosmetology/Practical Nursing (circle one) program and hereby give my permission to release this information.
Name of person completing this form (please print): _________________________________________________Date _________________ How long have you known the applicant? ______________________________________________________________________________
In what capacity or relationship to the applicant are you completing this reference? _____________________________________________ (Mark all that apply)
Employer ________ Immediate Supervisor ________ Co-worker ________ Friend ________ Counselor _________ Pastor/Priest ________ Teacher ________ Health Care Provider _________ Relative ________
From your experience with this individual rate the following characteristics. Check one level of performance for each category.
EXCELLENT GOOD FAIR POOR
8. INTEGRITY __________ _______ ________ _________ 9. DEPENDABILITY __________ _______ ________ _________ 10. PUNCTUALITY __________ _______ ________ _________ 11. INITIATIVE __________ _______ ________ _________ 12. MORAL/ETHICAL CHARACTER __________ _______ ________ _________ 13. INDUSTRIOUSNESS __________ _______ ________ _________ 14. GROOMING __________ _______ ________ _________
Do you know of any physical or emotional handicap that would influence this individual’s performance in their chosen program of study? YES_____ NO ______ If so, please specify
________________________________________________________________________________________________________________
Would you employ this individual for a position which requires responsibility and stability? YES______ NO______ If no, please state reason: ________________________________________________________________________________________________________________
Would you recommend to the Poplar Bluff Practical Nurse Program that this person be admitted to the program? YES_______ NO______ Additional Comments: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
In order that the applicant may be considered for admission, please complete this form and return it to the school at your earliest
convenience. Please DO NOT GIVE it to the applicant. The applicant WILL NOT be seeing this completed form at any time and it will be
destroyed after the application process has been completed. All information will be kept confidential. Feel free to contact the school for
any further information.
________________________________________________________________________________________________________________ Signature of Person Completing Form ____________________________________
Address State Zip ____________________________________________________
School Address: Poplar Bluff Practical Nurse Program 3203 Oak Grove Road
Poplar Bluff, MO 63901 (573) 785-6867
Poplar Bluff Technical Career Center Applicant Professional Reference Form
I, ___________________________________________________, DOB ___________________ have applied
for entrance to the Poplar Bluff Technical Career Center Cosmetology/Practical Nursing (circle one) program and hereby give my permission to release this information.
Name of person completing this form (please print): _________________________________________________Date _________________ How long have you known the applicant? ______________________________________________________________________________
In what capacity or relationship to the applicant are you completing this reference? _____________________________________________ (Mark all that apply)
Employer ________ Immediate Supervisor ________ Co-worker ________ Friend ________ Counselor _________ Pastor/Priest ________ Teacher ________ Health Care Provider _________ Relative ________
From your experience with this individual rate the following characteristics. Check one level of performance for each category.
EXCELLENT GOOD FAIR POOR
15. INTEGRITY __________ _______ ________ _________ 16. DEPENDABILITY __________ _______ ________ _________ 17. PUNCTUALITY __________ _______ ________ _________ 18. INITIATIVE __________ _______ ________ _________ 19. MORAL/ETHICAL CHARACTER __________ _______ ________ _________ 20. INDUSTRIOUSNESS __________ _______ ________ _________ 21. GROOMING __________ _______ ________ _________
Do you know of any physical or emotional handicap that would influence this individual’s performance in their chosen program of study? YES_____ NO ______ If so, please specify
________________________________________________________________________________________________________________
Would you employ this individual for a position which requires responsibility and stability? YES______ NO______ If no, please state reason: ________________________________________________________________________________________________________________
Would you recommend to the Poplar Bluff Practical Nurse Program that this person be admitted to the program? YES_______ NO______ Additional Comments: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
In order that the applicant may be considered for admission, please complete this form and return it to the school at your earliest
convenience. Please DO NOT GIVE it to the applicant. The applicant WILL NOT be seeing this completed form at any time and it will be
destroyed after the application process has been completed. All information will be kept confidential. Feel free to contact the school for
any further information.
________________________________________________________________________________________________________________ Signature of Person Completing Form ____________________________________
Address State Zip ____________________________________________________
School Address: Poplar Bluff Practical Nurse Program 3203 Oak Grove Road
Poplar Bluff, MO 63901 (573) 785-6867
