DEMOGRAPHIC INFORMATION

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1 AKRON SCHOOL OF PRACTICAL NURSING STUDENT APPLICATION APPLICATION FOR FULL-TIME PROGRAMS PROGRAM OF INTEREST FULL TIME DAY LPN PROGRAM August 2013 June 2014 January 2014 January 2015 August 2014 June 2015 STNA PROGRAM March 2013 July 2013 October 2013 DEMOGRAPHIC INFORMATION NAME SOCIAL SECURITY # Last First Middle BIRTH DATE ADDRESS Number Street City State Zip CELL PHONE NO. HOME PHONE NO. HAVE YOU PREVIOUSLY APPLIED FOR ADMISSION TO THIS SCHOOL? IF SO, WHEN? HAVE YOU PREVIOUSLY ATTENDED A SCHOOL OF NURSING? IF SO, WHERE & WHEN? WERE YOU REFERRED TO US BY A CURRENT OR FORMER STUDENT? IF SO, WHO CAN WE THANK FOR THE REFERRAL? IF YOU WERE NOT REFERRED TO US, HOW DID YOU LEARN OF OUR PROGRAM?

2 EDUCATIONAL BACKGROUND NAME OF HIGH SCHOOL CITY STATE WHAT WAS YOUR LAST NAME AT THE TIME YOU ATTENDED HIGH SCHOOL GPA DATE OF HS GRADUATION IF YOU DID NOT GRADUATE HS, DATE OF GED COMPLETION NAME OF COLLEGE/SCHOOL ATTENDED SINCE GRADUATING HIGH SCHOOL OR RECEIVING YOUR GED: SCHOOL YEARS ATTENDED (FROM/TO) DEGREE OR CERTIFICATE EARNED DID YOU GRADUATE (Y/N)? NOTE: YOU MUST SUBMIT AN OFFICIAL TRANSCRIPT FROM ANY SCHOOL YOU WISH TO BE EVALUATED FOR TRANSFER CREDIT. WORK EXPERIENCE PLEASE LIST ALL WORK EXPERIENCES, WITH THE MOST CURRENT INFORMATION FIRST TYPE OF WORK COMPANY NAME NAME OF SUPERVISOR DATES EMPLOYED REASON FOR LEAVING ATTENDANCE (GOOD, FAIR, OR POOR)

3 BOARD OF NURSING COMPLIANCE QUESTIONNAIRE Please circle a respose to each question below. Circling Yes does not automatically disqualify you from admission. 1. Have you EVER been convicted of, found guilty of, pled guilty to, pled no contest to, pled not guilty by reason of insanity to, entered an Alford plea, received treatment or intervention in lieu of conviction, or received diversion for any of the following crimes? This includes crimes that have been expunged IF there is a direct and substantial relationship to nursing practice. Please answer BOTH questions a and b. a. A felony in Ohio, another state, commonwealth, territory, province, or country? Yes No b. A misdemeanor in Ohio, another state, commonwealth, territory, province, or country? (This does Yes No not include traffic violations unless they are DUI/OVI) 2. Have you ever been found to be mentally ill or mentally incompetent by a probate court? Yes No 3. Has any board, bureau, department, agency or other body, including those in Ohio, other than this Yes No Board, in any way limited, restricted, suspended, or revoked any professional license, certificate, or registration granted to you; placed you on probation; or imposed a fine, censure, or reprimand against you? Have you ever voluntarily surrendered, resigned, or otherwise forfeited any professional license, certificate, or registration? 4. Have you ever, for any reason, been denied an application, issuance, or renewal for licensure, Yes No certification, registration, or the privilege of taking an examination in any state (including Ohio), commonwealth, territory, province, or country? 5. Have you ever entered into an agreement of any kind, whether oral or written, with respect to a Yes No professional license, certificate, or registration in lieu of or in order to avoid formal disciplinary action, with any board, bureau, department, agency, or other body, including those in Ohio, other than this Board? 6. Have you been notified of any current investigation of you, or have you ever been notified of any Yes No formal charges, allegations, or complaints filed against you by any board, bureau, department, agency, or other body, including those in Ohio, other than this board, with respect to a professional license, certificate, or registration? 7. Have you ever been diagnosed as having, or have you been treated for, pedophilia, exhibitionism, Yes No or voyeurism? 8. Within the last five years, have you been diagnosed with or have you been treated for bipolar Yes No disorder, schizophrenia, paranoia, or any other psychotic disorder? 9. Have you, since attaining the age of eighteen or within the last five years, whichever period is Yes No shorter, been admitted to a hospital or other facility for the treatment of bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder? 10. Are you currently engaged in the illegal use of chemical substances or controlled substances, now Yes No or during the past two years? a. If you answered Yes to question 10, are you currently participating in a supervised Yes rehabilitation program or professional assistance program which monitors you in order to assure that you are not illegally using chemical substances or controlled substances? No N/A If you answered Yes, you are required to provide a written explanation. If you are participating in a monitoring program, you are required to cause the respective program to provide information detailing your participation in and compliance with the program. 11. Have you been notified of any proceeding to determine whether you may be subject to listing on Yes No the Sexual Civil Child Abuse Registry established by the Ohio attorney general pursuant to section of the Revised Code, and/or are you listed on that registry? If you circled Yes to any question please explain on the reverse side. Your application will not be considered complete if you fail to explain any Yes question.

4 If you entered Yes to any question on the reverse side, please complete the following questions. 1. Question you circle Yes : Please explain: If the question relates to a criminal offense, please provide the ORC number: What was the final disposition? *You will be required to submit an official journal entry from the court system before an acceptance letter can be offered. 2. Question you circled Yes : Please explain: If the question relates to a criminal offense, please provide the ORC number: What was the final disposition? *You will be required to submit an official journal entry from the court system before an acceptance letter can be offered. 3. Question you circled Yes : Please explain: If the question relates to a criminal offense, please provide the ORC number: What was the final disposition? *You will be required to submit an official journal entry from the court system before an acceptance letter can be offered.

5 WRITTEN RESPONSE ON PERSONAL COMMITMENT AND GROWTH Your responses to these questions will be reviewed by the Admissions Committee. Please answer on a separate sheet of paper and attach to this application. Please TYPE your responses. 1. How did you hear about ASPN? Why did you choose our program over other programs? 2. Why are you an ideal candidate for our program? 3. Why does a career in nursing appeal to you? 4. How do you expect to juggle school and other adult responsibilities? 5. What do you think will be your greatest challenge with school? What will you do to help ensure you will be successful? You will be scored based on your thoughtfulness, completeness, and grammar. You will not be scored on the specific details you share (i.e., there are no right or wrong answers). Documentation is an important task within the world of Nursing. Please do not rush through this section of the application.

6 APPLICANT ATTESTATION I certify that the information I have given on this application is true and complete. I authorize investigation of all statements contained in this application and understand that by giving any false information, including that given at the time of the physical examination, is sufficient reason for dismissal from the program, if accepted. I understand that I will be expected to abide by all rules and regulations of the Akron School of Practical Nursing if accepted. Signature of Applicant Date Please check to see that you have answered all questions listed on the back of this page. Then mail this application with the required non-refundable application fee of $40.00 to: Akron School of Practical Nursing 1532 Peckham Street Akron, OH (330) (330) FAX You will receive a notice that we have received your application, along with the next steps if your application is completed in full. You should receive this confirmation within three weeks of submission. Thank you! The Akron Board of Education does not unlawfully discriminate on the basis of sex, age, race, color, religion, disability, political affiliation or national origin in employment or in its educational program and activities.

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