School of Nursing Application Packet for Admission to the RN to BSN Option

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Bellin College RN to BSN Application Packet 2015 | Instructions Page 1 of 7

School of Nursing

Application Packet for Admission

to the RN to BSN Option

Please follow the steps outlined below to complete your application.

A. To the Bellin Health Chief Nursing Officer, Laura Hieb, submit items 1-7 below:

Items #1 through #4 are fillable forms and contained in this packet. Save this document packet to

your electronic file location (flash drive, hard drive, desktop or other), complete the required fields,

print one-sided, sign and date where required, and submit to the Chief Nursing Officer’s office as

instructed below.

1. Complete the Request for Credit Evaluation (page 2). All applicants are required to have a credit

evaluation completed to determine which credits and how many credits apply toward the required

nursing and general education distributions.

2. Complete the Application for Admission (pages 3-5).

3. Authorize the release of your Background Information (page 6). Complete the top portion of the

form titled “Consent & Permission”.

4. Authorize the Release of your Health Information (page 7). Complete the top portion of the form

titled “Consent & Permission”.

5. Obtain a Professional Reference (see separate, accompanying Reference/Release Form) from your

team facilitator outlining his/her recommendation and support of your admission to, and participation

in, the program of study.

a.

Save the Reference/Release Form to your electronic file area, complete the applicant section,

and again save the document with your entries.

b.

Provide the Reference/Release Form via e-mail or in print to your identified reference and

ask that it be returned to your attention in a sealed envelope.

c.

Upon receipt, add the completed reference in the sealed envelope to your admission packet.

6. Provide your Professional Resume. An up-to-date synopsis of your education, employment, service,

and achievements is required. Your resume may be in the format of your choice.

7. Provide a copy of your BHS Application Essay submitted to the Bellin Health Chief Nursing Officer.

Submit items #A-1 through #A-7 above together as a print packet to the Chief Nursing Officer’s office

who will furnish it to the College.

B. To Bellin College:

1. Arrange for Official Transcripts from all of your post-secondary educational institutions be submitted

from each institution directly to the College’s Office of Admissions as follows:

Bellin College

Office of Admissions

3201 Eaton Road

Green Bay, WI 54311-6830

Phone: (920) 433-6650 / (800) 236-8707



Fax: (920) 433-1922



admissions@bellincollege.edu

All applications must be complete in order to meet any established deadline. An application is not

considered complete until all required items are received by the Office of Admissions.

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REQUEST FOR CREDIT EVALUATION

Bachelor of Science in Nursing | RN to BSN Option

Bellin College Office of Admissions 3201 Eaton Road

Green Bay, WI 54311‐6830

Phone: (920) 433‐6650 / Toll‐free: (800) 236‐8707 Fax: (920) 433‐1922 Visit our website: www.bellincollege.edu Email questions to: admissions@bellincollege.edu Instructions:

1. Complete this form.

2. Compile all transcripts. Unofficial transcripts are acceptable for this evaluation. Include transcripts from all educational institutions attended following high school AND any current colleges that identify courses in progress. When the Credit Evaluation has been completed, a Bellin College Admissions Representative will contact you to review results.

PERSONAL INFORMATION

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Last Name First Name Middle Name

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Maiden or Former Name Email Address Date of Birth (MM/DD/YYYY) Gender: ☐Female ☐Male

ADDRESS INFORMATION – Provide the address where you prefer to receive College mail

Primary Address (Street / Apt) City State / Zip Code / County

Telephone (Area Code + Number) Work Phone Cell Phone

POST‐SECONDARY EDUCATION – List all educational institutions attended following high school AND any current college

Name of Institution City and State

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I am requesting Bellin College to provide a Credit Evaluation for the purpose of assessing admission eligibility for the RN to BSN Option.

I understand this Credit Evaluation:

 will include transcripts from all of the post‐secondary institutions I have attended or in which I am currently enrolled.

 does not imply guaranteed admission and is not part of formal application to Bellin College.  will be based upon the current curriculum at Bellin College.

 will be retained at the College for 1 year and is only valid within the annual application cycle (whichever date comes first).

 is for planning purposes. If I choose to apply to the College, I must complete all application procedures, including the submission of a completed application; all official transcripts from all post‐secondary institutions; and an employer reference.

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Bellin College RN to BSN Application Packet 2015 | Application for Admission Page 3 of 7

APPLICATION FOR ADMISSION

Bachelor of Science in Nursing | RN to BSN Option

Bellin College Office of Admissions 3201 Eaton Road Green Bay, WI 54311‐6830 Phone: (920) 433‐6650 / Toll‐free: (800) 236‐8707 Fax: (920) 433‐1922 Visit our website: www.bellincollege.edu Email questions to: admissions@bellincollege.edu NON-DISCRIMINATION STATEMENT: It is the policy of Bellin College to be nondiscriminatory in the admission of students because of color, race, national origin, religion, age, sex, marital status or handicap.

SECTION 1 PERSONAL INFORMATION

Last Name: Click here to enter text. First Name: Click here to enter text. Middle Name: Click here to enter text. Previous Last Name(s): Maiden:Click here to enter text.

Other:Click here to enter text.

Preferred Name (nickname): Click here to enter text.

Soc Sec No: Click here to enter

text.  Gender: ☐Female ☐Male

Date of Birth (MM/DD/YYYY): Click here to enter text.

State of Wisconsin Registered Nurse (RN) License No.: Click here to enter text.

The following student data does not affect your admission status and is requested only to aid in the completion of federal, state, and college reports. 1. Ethnicity: Are you of Hispanic or Latino/a origin?

☐Yes ☐No

2. Race: Choose one or more from the list below: ☐American Indian/Alaska Native

Specify tribal affiliation: Click here to enter text.

☐Asian ☐Laotian ☐Cambodian ☐Vietnamese

☐Other: Click here to enter text. ☐Black/African American

☐Native Hawaiian/other Pacific Islander ☐White

Are you a U.S. Citizen? ☐Yes ☐No

If ‘No’, you must contact the Admissions Department.

Did either parent attend or complete college? ☐Yes ☐No Have you applied to Bellin College in the past? ☐Yes ☐No Have you taken a nursing course at another college? ☐Yes ☐No Are you a veteran? ☐Yes ☐No

If yes, select one: ☐Chapter 30 ☐Chapter 1606

☐Chapter 31 ☐Chapter 1607 ☐Chapter 33 ☐Unknown

Are you a dependent of a veteran? ☐Yes ☐No

SECTION 2 ADDRESS INFORMATION

Mailing Address: Alternate Address: (if applicable)

Street: Click here to enter text. ☐ Parent ☐ Other: Click here to enter text.

City:Click here to enter text.

State:Click here to enter text.

Street: Click here to enter text. Zip Code: Click

here to enter text.

County (if Wisconsin): Click here to

enter text. City: Click here to enter text.

State: Click here to enter text. E-mail Address: Click here to enter text. Zip Code: Click

here to enter text.

County (if Wisconsin): Click here to enter text.

Phone Number: Click here to enter text. Phone Number: Click here to enter text.

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SECTION 3 HIGH SCHOOL EDUCATION – Please provide the following information regarding your high school education.

Dates (MM/YYYY)

Name of School City and State Date Diploma

Received

GED or HSED Date From To

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SECTION 4 POST-SECONDARY EDUCATION – List all educational institutions attended following high school. IMPORTANT: Official transcripts MUST be mailed from institution directly to Bellin College to be accepted.

Dates (MM/YYYY)

Name of Institution City and State

From To

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SECTION 5 EMPLOYMENT – List employment history for last 2 years.

Dates (MM/YYYY)

Title of Position Employer City and State

From To

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SECTION 6 REFERENCE – (1) Employer reference is required

IMPORTANT: It is the Applicant’s responsibility to distribute the Reference/Release Form to his/her Team Facilitator.

Employer

Name: Click here to enter text. Position or Title: Click here to enter text.

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Bellin College RN to BSN Application Packet 2015 | Application for Admission Page 5 of 7 SECTION 7 CRIMINAL HISTORY

Do you have a conviction record or pending charges? ☐Yes (see below) ☐No

If you have a conviction not related to minor traffic violations, contact the Dean of Student Services for further direction before applying to the College. Bellin College reserves the right to deny admission or to terminate enrollment of any student

because of his or her criminal history.

If any of the information provided in this application changes during your enrollment at Bellin College, you agree to supplement this application with additional information.

It is understood and agreed that any misrepresentation, false statements, or omissions by me in this application or during any interview conducted in connection with my application, may result in denial of acceptance to Bellin College or termination of my status as a student of Bellin College without liability to the College.

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Bachelor of Science in Nursing | RN to BSN Option

Background Information

CONSENT & PERMISSION

I hereby grant permission

 to Bellin Health to release my criminal background information, including but not limited to my Background Information Disclosure form and reports, to Bellin College as a condition of my admission to RN to BSN program. In addition, upon admission and throughout my tenure as a student at Bellin College, I consent to Bellin Health’s continued provision of updated background information in order for me to maintain my student status; and

 to Bellin College to release my background information to any agency that requests this information as a condition of my involvement in, or placement within its facility for an educational learning experience as part of my program of study with the College. My permission to release my background information in this circumstance is granted throughout my tenure as a student at Bellin College.

Furthermore I understand that I am responsible to report any pending or actual criminal charges to the Dean of Student Services as soon as possible and no later than within two business days as per College policy.

Printed Name Date of Birth

PLEASE PRINT FIRST, MIDDLE, AND LAST NAMES MM/DD/YYYY

Signature Date

VERIFICATION OF REQUIREMENTS

I hereby verify that the above named Bellin Health employee has current and negative criminal background information on file. I confirm that this employee is in good standing and that updated background information will be provided to the College as required to maintain his/her program standing.

 Background Information Disclosure Form (BID)

 Dept of Justice Criminal Background Check http://wi-recordcheck.org/ - updated every four years

 Dept of Health and Family Services Caregiver Background Check (DHFS) http://wi-recordcheck.org/ - updated every four years

 HHS Office of the Inspector General Exclusions check http://exclusions.oig.hhs.gov/ - updated every four years

 SAM (formerly EPLS) check: https://www.sam.gov/portal/public/SAM - updated every four years

Bellin Health Representative Printed Name Representative Title

PLEASE PRINT FIRST, MIDDLE, AND LAST NAMES

Bellin Health Representative Signature Date Excellence, Integrity, Community, Caring

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Bellin College RN to BSN Application Packet 2015 | Health Information Page 7 of 7

Bachelor of Science in Nursing | RN to BSN Option

Health Information

CONSENT & PERMISSION

I hereby grant permission to Bellin Health to release my health information, including but not limited to, medical / health / immunization / toxicology (drug screen) data, to Bellin College as a condition of my admission to RN to BSN program. In addition, upon admission and throughout my tenure as a student at Bellin College, I consent to Bellin Health’s continued provision of updated health information in order for me to maintain my student status.

Furthermore, I grant permission to Bellin College to release my health information to any agency that requests this information as a condition of my involvement in, or placement within its facility for an educational learning experience as part of my program of study with the College. My permission to release my health information in this circumstance is granted throughout my tenure as a student at Bellin College.

Printed Name Date of Birth

PLEASE PRINT FIRST, MIDDLE, AND LAST NAMES MM/DD/YYYY

Signature Date

VERIFICATION OF REQUIREMENTS

I hereby verify that the above named Bellin Health employee fulfills the program health requirements as listed below. I confirm that this employee is in good health status and that updated health information will be provided to the College as required to maintain his/her program standing.

 Drug Screen: Negative toxicology results

 Flu Vaccination: Evidence of receipt of the flu vaccine by November 1 annually

 Hepatitis B: Positive immune blood titer. If vaccine series was completed more than 6 months ago, documentation of that series (3 shots) will be adequate. If titer was performed within 1-6 months after series and is non-immune, additional shots and titer(s) will be required up to a maximum of 6 shots. Immune titer is required if last dose is within 6 months.

 Measles: Positive immune blood titer or dates of two vaccines

 Meningococcal: Date of 1 vaccine, or signed declination

 Mumps: Positive immune blood titer or dates of two vaccines

 Rubella: Positive immune blood titer or dates of two vaccines

 Varicella: Positive immune blood titer or dates of two vaccines. If history of Chickenpox, a blood titer is required showing proof of sufficient immunity.

 Tetanus: Td or Tdap is required. A booster is required every 10 years.

 Tuberculosis Screening: Baseline screening using two-step skin test or single blood assay test with annual testing thereafter

o A negative Quantiferon blood test, and a completed Signs/Symptoms sheet, or

o A negative baseline chest x-ray, and a completed Signs/Symptoms sheet, (a Quantiferon blood test is recommended), or

o If a positive Quantiferon blood test, a negative baseline chest x-ray and a completed Signs/Symptoms sheet.

Bellin Health Representative Printed Name Representative Title

PLEASE PRINT FIRST, MIDDLE, AND LAST NAMES

Bellin Health Representative Signature Date Excellence, Integrity, Community, Caring