LEARN ON DEMAND LPN-ADN
PROGRAM APPLICATION PACKET
Dear Student,
Please complete this entire application packet in order to be considered for admission into the KCTCS Online LPN-ADN program. Please mail, fax, or scan and email your completed packet (do not send pages separately) to:
Jefferson Community and Technical College KCTCS Online: Learn on Demand
LPN to Associate Degree Nursing Program 109 East Broadway
Louisville, Kentucky 40202 Attention: Dr. Margie Charasika
JEFFERSON COMMUNITY & TECHNICAL COLLEGE
LPN-ADN PROGRAM APPLICATION PACKET
PROGRAM APPLICATION
Please PRINT
Last Name: First Name: Student ID#:
Address: City: State: Zip Code:
Phone 1: Phone 2: Employer: Phone: List All Colleges Attended:
Medications (optional):
Allergies (optional):
ORDER OF PREFERENCE TO BE CONTACTED IN AN EMERGENCY: 1. Name: Phone: Relationship: 2. Name: Phone: Relationship: Comments:
I completed the: [ ] LPN-ADN ONLINE ORIENTATION
[ ] TYPHON NURSING SCHOOL STUDENT TRACKING SYSTEM (NSST) TUTORIAL
JEFFERSON COMMUNITY & TECHNICAL COLLEGE
LPN-ADN PROGRAM APPLICATION PACKET
TECHNICAL STANDARDS FORM
NOTE: THIS IS THE ONLY OFFICIAL COLLEGE POLICY STATEMENT REGARDING THE ASSOCIATE DEGREE NURSING PROGRAM
The degree of Associate in Applied Science in Nursing is awarded upon completion of the program. The graduate is then eligible to take the state licensing examination to become a registered nurse.
Admission to the program is open to all qualified students.
Jefferson Community and Technical College does not discriminate on the basis of race, color, national origin, age, marital status, sex or handicap in employment, educational programs or activities as set forth in Title IX of the Educational Amendment of 1972, Title VI of the Civil Right Act of 1964 and Section 504 of the Rehabilitation Act of 1973.
Nursing at the technical level involves the provision of direct care for individuals and is
characterized by the application of admission verified knowledge in the skillful performance of nursing functions. Therefore, in order to be considered for admission or to be retained in the program after admission, all applicants should possess:
1. Sufficient visual acuity such as needed in the accurate preparation and administration of medications, and for the observation necessary for client assessment and nursing care. 2. Sufficient auditory perception to receive verbal communication from patients and members
of the health team and to assess health needs of people through the use of monitoring devices such as cardiac monitor, stethoscope, IV infusion pumps, Doppler, fire alarms etc. 3. Sufficient gross and fine motor coordination to respond promptly and to implement the
skills, including the manipulation of equipment, required in meeting health needs.
4. Sufficient communication skills (speech, reading, writing) to interact with individuals and to communicate their needs promptly and effectively, as may be necessary in the individuals' interest.
5. Sufficient intellectual and emotional function to plan and implement care for individuals.
"I have read and understand the above technical standards that I must be able to achieve and maintain while enrolled in the nursing program. I will notify the program coordinator if I should need any special accommodations."
Signature: Date:
JEFFERSON COMMUNITY & TECHNICAL COLLEGE
LPN-ADN PROGRAM APPLICATION PACKET
IMMUNIZATION VERIFICATION
Dear Healthcare Provider,
In order for the student below to be enrolled in the KCTCS LPN- ADN Program, we must have your signature (stamps will not be accepted) verifying that they are current on all immunizations. Date of immunization administration or verification is also required.
Student Signature: Date:
First Name: Last Name: Student ID#:
Required Immunization:
Recommended Vaccination:
The following vaccines are strongly encouraged but not required at this time.
Tetanus : (must be current for 3 years from today’s date)
Date of administration:
[ ] Td [ ] DTP/D-Tap [ ] T-dap
Hepatitis Vaccine:
If you have started or completed, check yes for vaccine. If you haven’t had the series or titer, please check “declined.”
[ ] YES [ ] NO [ ] Titer [ ] Declined
TB: (Fill out even if not verified or obtained by family Healthcare Provider)
[ ] Skin test Date of Test: Results of test: [ ] Chest X-ray: Date of Test: Results of test:
If previous positive reactor to skin test & CXR older than 1-year, is there symptoms of Tb?
[ ] YES [ ] NO
Influenza:
[ ] YES [ ] NO [ ] Declined Date administered:
Note: If you attended a Jefferson County Public
School, it may be possible that the Healthcare Provider signing this form will accept a copy of your high school diploma as verification that you have had the required childhood immunizations. Also, it is a good idea to attach a copy of your high school diploma with this form for your file.
MMR:
Completed series (2) or positive titer [ ] YES [ ] NO Born before 1957 (assumed immunity) – Copy of Drivers License
Healthcare Provider Signature: Date:
First Name: Last Name:
JEFFERSON COMMUNITY & TECHNICAL COLLEGE
LPN-ADN PROGRAM APPLICATION PACKET
IMMUNIZATION VERIFICATION
CONTINUEDPERSONAL HISTORY VERIFICATION FORM
CHICKEN POX (Varicella)
______ I do or a family member does recall my having Chicken Pox as a child.
______ I do NOT nor does a family member recall my having Chicken Pox as a child.
WHOOPING COUGH (Pertussis)
______ I do or a family member does recall my having Whooping Cough as a child.
______ I do NOT nor does a family member recall my having Whooping Cough as a child.
Student Signature: Date:
First Name: Last Name: Student ID#:
JEFFERSON COMMUNITY & TECHNICAL COLLEGE
LPN-ADN PROGRAM APPLICATION PACKET
CLINICAL LIABILITY INSURANCE FORM
PLEASE PRINT:
Last Name: First Name: Middle Initial:
Street: City: State: Zip:
Student ID#:
Annual student premium is $20.00 (prorating is not permitted). This $20.00 fee will be charged to your account for each coverage period and can be paid along with your tuition. You will be accessed this fee when you register for your first LPN-ADN course.
Your signature will be required again for the next coverage period (see below). Students must be enrolled in the professional liability insurance program prior to any clinical (patient care) activity.
Policy period is for one (1) year from start date of the semester.
This form will be returned for your signature at the beginning of each new term.
Complete, sign, & date only in BLACK or DARK BLUE INK (by ALL red X’s) for the first term. By signing below in Black/Dark Blue INK, you agree to notify the Nursing Program Office & the Business Office in writing within 24 hours of any incident that may result in a claim.
Coverage Period
Student Signature : Date: From:
(For Office Use Only)
To:
(For Office Use Only)
JEFFERSON COMMUNITY & TECHNICAL COLLEGE
LPN-ADN PROGRAM APPLICATION PACKET
ADDITIONAL DOCUMENTATION REQUIRED
1. Evidence of CPR certification- copy of front and back of card
2. Current status as Kentucky Licensed Practical Nurse- Master Advisor will reference registry (Requires no action on the part of the student)
3. College Transcripts- Please send your official transcripts to the Jefferson registrar/records office and an unofficial copy with this application packet. Please mail your official transcript to:
Jefferson Community and Technical College Registrar/Records Office
109 East Broadway Louisville, KY 40202
To be considered for acceptance into the program, your transcript will need to reflect a combined GPA of 2.75 in nursing required general education courses and demonstrate completion of the following pre-requisite courses:
Computer Literacy (OST 105 or CIS 100) – Not included in the 2.75 GPA calculation BIO 137 and BIO 139(with a grade of “C” or better and within a period of 10 years) PY 110 or PSY 100 and PSY 223
ENG 101
Oral Communication Course
MT 110 or MT 150 (with a grade of “C” or better)
Please mail, fax, or scan and email this entire packet with required documentation to:
Jefferson Community and Technical College KCTCS Online: Learn on Demand
LPN to Associate Degree Nursing Program 109 East Broadway
Louisville, Kentucky 40202 Attention: Dr. Margie Charasika
Academic Program Coordinator/Master Advisor
