NURSING APPLICATION FOR ADMISSION ASSOCIATE DEGREE

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1 YOU ARE NURSING APPLICATION FOR ADMISSION ASSOCIATE DEGREE 1 Program Information 2 Application Form 3 Financing Your Education 4 Financial Aid Checklist 5 Reference Form 1

2 A.D.N. PROGRAM INFORMATION ITEM Course Format Evenings and Weekends or Afternoons and Weekends; Fall, Spring, and Summer Academic Terms Begin Fall and Spring Deadline* for Receipt of Applications, Fee and all Supporting Documents Fall: April 1 Spring: September 1 Application Fee $50 ($20 to submit online) Personal Statement or Essay Required Official Transcripts from all Universitys Required Prerequisite Self-Reporting Checklist Required Official High School Transcript and SAT or ACT Required if fewer than 15 University units will transfer References Two Reference Forms International Students Additional Documents TOEFL: minimum 550 (paper-based) or 213 (computer-based) or 75 (internet-based) and International Transcript Evaluation Foreign Transcript Testing Requirements Admission Exam Interview Required (applicants will be contacted after application review) GPA Requirements Minimum 2.75 academic GPA and 2.5 science GPA (completed within the last 5 years of entry into the program science prerequisites only) Approximate Yearly Tuition and Fees Tuition: $806 (per unit) Nursing Department Fee: $300 (per semester) On-Campus Housing Not Available Financial Aid Opportunities Federal and State Grants and Loans; Alternative Loans * Date by which applications and supporting documents must be received to guarantee consideration for admission to the class beginning that term. 2

3 NURSING APPLICATION FOR ADMISSION Please print clearly with a pen or apply online at Please indicate the program year to which you are applying: A.D.N. Associate Degree in Nursing Fall of 20 (or) Spring of 20 L.V.N. 30-Unit Option Fall of 20 (or) Spring of 20 Do you hold an L.V.N. license? Yes* No (*Note: All L.V.N. s must submit official documentation of curriculum completed.) IF YES, PLEASE PROVIDE YOUR LVN LICENSE NUMBER: IF YES, WHERE DID YOU COMPLETE YOUR PROGRAM? PERSONAL INFORMATION NAME: FEMALE MALE Last (Family) First Middle OTHER LEGAL/MAIDEN NAME(S) UNDER WHICH ACADEMIC RECORDS MAY BE FOUND: HOME ADDRESS: Number And Street City State Zip PREVIOUS ADDRESS IF YOU HAVE APPLIED OR INQUIRED USING AN ALTERNATE ADDRESS: Number And Street City State Zip PHONE: CELL PHONE: S.S.#: DATE OF BIRTH: / / CITY/STATE OF BIRTH: ARE YOU A CITIZEN OR PERMANENT RESIDENT OF THE U.S.? YES NO IF NOT, WHICH COUNTRY? IF YOU WERE NOT BORN IN THE U.S., HOW LONG HAVE YOU LIVED HERE? CURRENT OR MOST RECENT COLLEGE OR UNIVERSITY: OPTIONAL INFORMATION The following information will be used for statistical purposes and planning only. Are you Hispanic/Latino? Yes No Check all that characterize your race: American Indian or Alaska Native Asian White Black or African American Native Hawaiian or Other Pacific Islander (Note: Regardless of your answer to the previous question, please mark one or more races to indicate what you consider yourself to be.) YOUR RELIGIOUS PREFERENCE: LANGUAGE SPOKEN AT HOME: Will you be applying for financial assistance? Yes No Are any of your friends or relatives graduates or affiliates of Mount Saint Mary s University? Yes No IF YES, THE NAME(S) AND RELATIONSHIP TO YOU: 3

4 EDUCATIONAL INFORMATION Please list in chronological order all schools, Universitys, and universities you have attended. Official transcripts from each institution must be sent directly to the Admissions Office. Attach a separate sheet if necessary. Students who have completed foreign education course work are required to provide an official, comprehensive international transcript evaluation and official foreign transcripts. Please contact the Admissions Office for more information. SCHOOL/UNIVERSITY & LOCATION DATES OF ATTENDANCE DEGREE AWARDED MAJOR WHERE DID YOU GRADUATE FROM HIGH SCHOOL? High School City, State Year Please list all courses you are currently taking or will take to complete prerequisite/general education requirements. If you are applying for Spring 2016, we will need transcripts that show classes taken through Summer If you are applying for Fall 2015, we will need transcripts that show classes taken through Fall Attach a separate sheet if necessary. COURSE NUMBER/TITLE UNITS COMPLETION DATE COLLEGE/UNIVERSITY Please list all classes you plan on taking before starting with us. The space above is provided for you to inform us about your academic plans prior to starting in our program. This information is used to determine the option for which you will be considered. Once you have submitted your application, you will be unable to report to us additional courses you plan to take. Failure to inform us about courses you plan to take prior to starting with us, will jeopardize your admission into the program. Have you ever been enrolled in an R.N. nursing program? Yes No IF YES, WHERE? Did you complete the program and sit for boards? Yes No IF YES, WHEN DID YOU SIT FOR BOARDS? 4

5 SESSION AVAILABILITY Mount Saint Mary s University Associate Degree in Nursing Program offers two cohorts: an afternoon (12:30 p.m. - 4:30 p.m.) and an evening (5:30 p.m. - 9:30 p.m.) session. Please indicate your session of preference. Note: There is no guarantee of which session you will be assigned. Afternoon (12:30 p.m. - 4:30 p.m.) Evening (5:30 p.m. - 9:30 p.m.) ESSAY OR PERSONAL STATEMENT Please respond to the questions and attach your statement of two to three typewritten pages to the application. Your file will not be complete until this is received. 1. Why are you choosing a career in nursing at this time? 2. What talents and qualities do you possess to make you a strong candidate for this program? 3. What are your short- and long-term career goals? 4. Please discuss any educational challenges you may have encountered in the pasaint 5. How have you planned to be successful in the A.D.N. Program? LETTERS OF REFERENCE Please submit two letters from those who are acquainted with your ability to succeed in an academically rigorous and fastpaced nursing program. These letters must be submitted on the references official letterhead. Please list the names and telephone numbers of your reference(s): NAME: PHONE: NAME: PHONE: WORK/PROFESSIONAL/VOLUNTEER EXPERIENCE Please list all employment and/or volunteer experience for the last five years. Attach a separate sheet if necessary. POSITION DATES OF EMPLOYMENT HOURS/WEEK COMPANY/INSTITUTION DISCIPLINARY HISTORY 1. Have you ever been found responsible for a disciplinary action at any educational institution you have attended from 9th grade (or the international equivalent) forward, whether related to academic misconduct or behavioral misconduct, that resulted in your probation, suspension, removal, dismissal or expulsion from the institution? Yes No 2. Have you ever been convicted of a misdemeanor, felony or other crime? Yes No Note that you are not required to answer yes to this question, or provide an explanation, if the criminal adjudication conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded or otherwise ordered by a court to be kept confidential. If you answered yes to either or both questions, please attach a separate sheet of paper that gives the date of each incident, explains the circumstance and reflects on what you ve learned from the experience. Your reference will also be asked this question of your record. 5

6 EDUCATIONAL PLANS HOW DID YOU LEARN ABOUT MOUNT SAINT MARY S UNIVERSITY S NURSING PROGRAM? TO WHICH OTHER COLLEGES/UNIVERSITIES DO YOU PLAN TO APPLY? SIGNATURE Enrollment at Mount Saint Mary s University signifies a students willingness to conduct oneself in accordance with the appropriate standards of personal behavior and to adhere to the academic policies and other regulations stated in the catalog. Please read and sign the following statement: I understand that if I enroll at Mount Saint Mary s University I am expected to become a responsible member of the student body and act accordingly. To the best of my knowledge all the information provided on this application is accurate. SIGNATURE: DATE: Please return any necessary accompanying documents to: Doheny Campus 10 Chester Place Los Angeles, CA

7 APPLICANT SELF REPORTING CHECKLIST ASSOCIATE DEGREE OF SCIENCE PROGRAM Please complete the following information regarding your current academic profile. Attach a separate sheet if necessary. SCIENCE REQUIREMENTS: For eligibility to Mount Saint Mary s A.D.N. Program, the following science courses need to have been successfully completed within the last 5 years of entry into the program. In addition, grades below a C will not be accepted. A minimum 2.75 academic GPA and 2.5 science GPA is required. NO. OF TIMES COURSE HAS BEEN TAKEN SCIENCE PRE-REQUISITES LIST ALL CORRESPONDING INSTITUTIONS GRADE/TERM (IF IN PROGRESS, PLEASE STATE IP ) NAME OF COURSE UNITS EXAMPLE: 2 Chemistry w/lab Best University City University D / SP03 B / FA07 Introduction to Chemistry Chemistry Fundamentals 4 4 Chemistry w/lab Anatomy w/lab Physiology w/lab Microbiology w/lab GENERAL REQUIREMENTS: Please indicate all that apply. NO. OF TIMES COURSE HAS BEEN TAKEN GENERAL PRE-REQUISITES LIST ALL CORRESPONDING INSTITUTIONS GRADE/TERM (IF IN PROGRESS, PLEASE STATE IP ) NAME OF COURSE UNITS General Psychology English 1A English 1B Public Speaking or Oral Communication Developmental Psych (Lifespan Infancy thru Death) Philosophy/ Critical Thinking or Logic Intro to Sociology General Studies Elective SIGNATURE By completing this form, you acknowledge that the above information is correct. You also acknowledge that any misrepresentation of your academic qualifications could result in your disqualification from admission into the A.D.N. Program at Mount Saint Mary s University. I certify that the above information is an accurate representation of my academic profile. PRINT NAME: SIGNATURE: DATE: 7

8 FINANCING YOUR MSMU EDUCATION Mount Saint Mary s University is committed to assisting students find the funds necessary to pay for their education at the Mount. It is important for students to realize that the responsibility for funding their degree or certificate programs rests with the student and her/his family. The information below outlines the process necessary to apply for financial aid and the types of aid available to students enrolling in our nursing programs. If you have any questions regarding the process or your individual financial aid package, please contact the Office of Student Financing at AID ELIGIBILITY Each admitted student will receive a financial aid package based upon his/her individual financial situation and program. The package will contain all sources of aid for which the student is eligible. All admitted students who have not previously defaulted on a student loan will be eligible for some form of Subsidized or Unsubsidized Federal Stafford Loan. Information on these loans will be included in the financial aid packages received by admitted students, based on their individual eligibility. Additional alternative loans may also be available to qualified students. PLAN YOUR FINANCING It is important that you plan the financing of your education very carefully in order to remain eligible for the maximum amount of aid you may receive. 1. To be eligible for federal loans or state grants, students must be enrolled in a minimum of six units each semester. 2. We encourage you to meet with a member of the Student Financing Staff to discuss your plans for enrollment. You will only receive aid for the semesters you are enrolled. Note: there are limits on the amount of aid you may receive within one year, so planning is important. 3. If you decide to delay entering your program, make sure that you notify your program director and the Office of Student Financing of your intention to enter at another specified time. 4. Once you are enrolled, if you decide to take a leave of absence from your program, you must be sure that the proper forms are completed and sent to the Registrar s Office. Mount Saint Mary s University is committed to providing an educational environment that is free from discrimination. The University prohibits all forms of unlawful discrimination in the administration of its admission policies, scholarship and loan programs, or in its educational programs, on the basis of sex, sexual orientation or preference, gender, gender identity, race, color, religion, national origin, creed, citizenship status, ancestry, age, marital status, pregnancy, childbirth or related medical conditions, medical conditions including genetic char-acteristics, mental or physical disability, veteran status or any other characteristic protected by federal, state or local law, ordinance or regulation. 8

9 FINANCIAL AID CHECKLIST Step 1 Apply for Aid at the Same Time You Apply for Admission While you are applying for admission to the University, you should also be applying for financial aid. Do not wait to learn of your admission to begin the process. Step 2 Complete and Send the FAFSA To be considered, all students must complete the FAFSA (Free Application for Federal Student Aid) which is available online. Please complete the FAFSA online by going to Our school code is Once submitted, an electronic version will be delivered to MSMU. A.D.N. STUDENTS This form should be mailed at least ten weeks prior to the beginning of the term you wish to begin your studies Step 3 Follow the Directions from the Office of Student Financing Once you ve completed the admission process and if you are admitted, the Student Financing staff will be notified by your department, (please note that you must be fully admitted to a degree or certificate program in order to receive financial aid.) Follow the instructions which will be sent to you by the Office of Student Financing very carefully. You may be asked to send additional documents. Delays on your part will delay your receipt of a financial aid package to fund your education. Step 4 Review Your Financial Aid Package After you receive your financial aid package, review it and call our office with any questions you might have. Once your questions have been answered, complete and sign the proper forms and return them to the Office of Student Financing. Step 5 Review Your Payment Plan Options Prior to the beginning of class, you will be required to settle your bill. A.D.N. students may either pay their bill in full or utilize the MSMU deferred payment plan. Questions? Call the Office of Student Financing at Doheny Campus 10 Chester Place Los Angeles, CA

10 NURSING LETTER OF REFERENCE TO THE APPLICANT: Mount Saint Mary s recognizes the importance of honest and confidential references in assessing each applicant s aptitude for undergraduate study. Under the provisions of the Family Education Rights and Privacy Act of 1974, you are guaranteed the right of access to your files. Please indicate below whether you are willing to waive your right of access to this letter of reference once it is completed. I hereby waive my right of future access to this letter of reference. I hereby do not waive my right of future access to this letter of reference. I understand that a waiver of access to my file is not required as a condition for admission, receipt of financial aid or any other services. Give this recommendation form to your reference with a stamped envelope addressed to: Doheny Campus 10 Chester Place Los Angeles, CA PRINTED NAME OF APPLICANT: Last (Family) First Middle ADDRESS: Number and Street City State Zip PHONE: APPLICANT S SOCIAL SECURITY#: APPLICANT SIGNATURE: DATE: TO THE REFERENCE: Your careful estimate of the applicant s qualifications is appreciated. Please check the response best describing the -student s potential for success in the following categories. CHARACTER & PERSONALITY EXCEPTIONAL ABOVE BELOW POOR UNABLE TO ASSESS Initiative/motivation Leadership Integrity Interpersonal ability Please give these 2 pages to your reference. PDF14 Acceptance of guidance/direction Ability to conduct self-assessment To your knowledge, has the applicant ever been subject to any disciplinary action? Yes No I don t know IF YES, PLEASE EXPLAIN: 10

11 ACADEMIC/PROFESSIONAL CHARACTERISTICS EXCEPTIONAL ABOVE BELOW POOR UNABLE TO ASSESS Written communication Oral communication Interpersonal communication Time management Abstract reasoning/problem solving Creativity Growth capacity and aptitude Intellectual ability OVERALL RECOMMENDATION Overall estimate of success in the program at Mount Saint Mary s University: Exceptional Above Average Average Below Average May encounter some difficulty Poor HOW LONG HAVE YOU KNOWN THE APPLICANT? HOW WELL DO YOU KNOW THE APPLICANT AND IN WHAT CAPACITY? What do you consider to be the applicant s outstanding talents and strengths? Please give specific examples. Please feel free to use additional sheets if necessary. How well do you think the applicant has thought out his/her plan for this program of study? General comments: SIGNATURE: DATE: TYPED OR PRINTED NAME: POSITION: COMPANY/INSTITUTION: PHONE: 11

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