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

Transcription

1 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 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 Phone: (920) / (800) Fax: (920) 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. Bellin College RN to BSN Application Packet 2015 Instructions Page 1 of 7

2 REQUEST FOR CREDIT EVALUATION Bellin College Office of Admissions 3201 Eaton Road Green Bay, WI Phone: (920) / Toll free: (800) Fax: (920) Visit our website: 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 Last Name First Name Middle Name enter a date. Maiden or Former Name Address 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 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. Signature Bellin College RN to BSN Application Packet 2015 Request for Credit Evaluation Page 2 of 7

3 Bellin College Office of Admissions 3201 Eaton Road Green Bay, WI APPLICATION FOR ADMISSION Phone: (920) / Toll free: (800) Fax: (920) Visit our website: 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: First Name: Middle Name: Previous Last Name(s): Maiden: Other: Soc Sec No: enter Gender: Female Male State of Wisconsin Registered Nurse (RN) License No.: Preferred Name (nickname): of Birth (MM/DD/YYYY): enter 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: enter Asian Laotian Cambodian Vietnamese Other: 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: Street: City: Zip Code: Click here to enter Address: Phone Number: State:Click here to enter County (if Wisconsin): Cell Phone Number: Alternate Address: (if applicable) Parent Other: Street: City: Zip Code: Click here to Phone Number: State: Click here to enter County (if Wisconsin): Cell Phone Number: Bellin College RN to BSN Application Packet 2015 Application for Admission Page 3 of 7

4 SECTION 3 education. s (MM/YYYY) From To enter HIGH SCHOOL EDUCATION Please provide the following information regarding your high school enter Name of School City and State Diploma Received GED or HSED 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. s (MM/YYYY) From To Name of Institution City and State SECTION 5 s (MM/YYYY) From To EMPLOYMENT List employment history for last 2 years. Title of Position Employer City and State 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: Position or Title: Address: Bellin College RN to BSN Application Packet 2015 Application for Admission Page 4 of 7

5 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. Applicant Signature Bellin College RN to BSN Application Packet 2015 Application for Admission Page 5 of 7

6 Excellence, Integrity, Community, Caring 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 of Birth MM/DD/YYYY Signature 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 - updated every four years Dept of Health and Family Services Caregiver Background Check (DHFS) - updated every four years HHS Office of the Inspector General Exclusions check - updated every four years SAM (formerly EPLS) check: - updated every four years Bellin Health Representative Printed Name Representative Title Bellin Health Representative Signature Bellin College RN to BSN Application Packet 2015 Background Information Page 6 of 7

7 Excellence, Integrity, Community, Caring 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 of Birth MM/DD/YYYY Signature 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: 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 Bellin Health Representative Signature Bellin College RN to BSN Application Packet 2015 Health Information Page 7 of 7