ADMISSION INFORMATION

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1 ADMISSION INFORMATION Lake-Sumter State College Nursing Program is a limited access program. Students must meet certain criteria before applications forward to the Nursing Selection Committee for admission consideration. Consult the Nursing Information Packet located on the web at for complete details regarding Admission Requirements, Application Procedure, Selection Criteria, and Selection Process. Applicants who did not attend a mandatory program information session prior to application return deadline will not forward to program admission selection committee. APPLICATION RETURN DEADLINES BRIDGE March 1, 2016 GENERAL March 1, 2016 APPLICATION RETURN PROCEDURE Submit original Application form (pages 1-3) plus Attachments applicable to you by mail or in person. Applications must be physically received in the nursing offices on Leesburg or South Lake campuses by the end of the business day of the application return deadline. Post mark dates are not considered receive dates. CONTACT INFORMATION LEESBURG SOUTH LAKE Nursing Main Phone Nursing Website Nursing Address

2 APPLICATION ATTACHMENTS CHECKLIST Only complete applications forward to program admission selection committee. Only attachments listed below are accepted with the application. All unrequested material is destroyed. Make copies required for submission and/or for your records prior to surrendering application. ALL applicants: Proof of Residency: Attach copy of FL Driver s License or Vehicle Registration (in your name). Education Verification: High School Health Occupations curriculum- If checking YES box, submit documentation to Manager Workforce Services- Tech Prep, Student Services Building- Room 228, Leesburg Campus by application return deadline. Grade Amnesty: Attach copy of request (if applicable). Course Substitution(s): Attach copy of request(s) (if applicable). LPN-BRIDGE applicants only: License: Attach 2 copies of current Florida LPN License. (2 pages. License information only.) Transcripts: Attach sealed, official copy of transcripts from institution where LPN program completed. PARAMEDIC-BRIDGE applicants only: Certification: Attach 2 copies of current Florida Paramedic Certification. (2 pages. License information only.) Transcripts: Attach sealed, official copy of transcripts from institution where Paramedic program completed. DIRECTIONS FOR COMPLETION Complete sections 1-4 and 5a or 5b (according to track/option selection) of the application (pages 1-3). This applies to section 5a or 5b: o Write course sub in Term/Year column for courses you submitted course substitution forms. This applies to section 5a only: o Write Spring Semester end date for courses in progress at non LSSC institution in space provided. o Write in progress in Term/Year column for courses in progress this spring semester. Double check: 1) all blanks completed 2) all attachments per the ATTACHMENTS CHECKLIST.

3 LAKE-SUMTER STATE COLLEGE NURSING PROGRAM ADMISSION APPLICATION 2016 Lake-Sumter State College is committed to non-discrimination based on race, color, sex, ethnicity, gender, national origin, age, disability, genetic information, marital status, veteran status, religion, sexual orientation, political affiliation and pregnancy. This commitment applies in all areas to applicants, visitors, students, faculty, administrators, staff, and others affiliated with the College. 1. COVER INFORMATION APPLICANT NAME (print) PROGRAM TRACK/(Option) LAST: FIRST: XID #: GENERAL (Preferred) GENERAL (Compressed) LPN-BRIDGE PARAMEDIC-BRIDGE Please accept my application for admission to the Associate Degree Nursing Program. I understand in order to be considered for admission I must meet all requirements and furnish all necessary documentation. I attest all information presented in this application is accurate and true and verify I physically reside in the County of Residence indicated. Signature: Date: 1

4 LSSC NURSING DEPARTMENT ADMISSION APPLICATION CONTACT INFORMATION (type or print legibly) LAST NAME FIRST NAME MIDDLE INITIAL M GENDER (select one) XID NUMBER DATE OF BIRTH COUNTY OF RESIDENCE F MAILING ADDRESS CITY STATE ZIP STREET ADDRESS (if different than mailing address) CITY STATE ZIP PLACE OF EMPLOYMENT JOB TITLE WORK PHONE (include area code) HOME PHONE (include area code) CELL PHONE (include area code) LAKEHAWK ADDRESS 3. EDUCATIONAL BACKGROUND All Applicants High School Health Occupations Curriculum? BRIDGE Track Students Only LPN or PARAMEDIC School Attended: Yes No (If yes, submit documentation to Manager Workforce Services- Tech Prep, by application return deadline.) (On separate pages-- Attach 2 copies of current Florida LPN license or PARAMEDIC certification.) 4. FLORIDA BOARD OF NURSING RULE 64B ACKNOWLEDGEMENT Rules of the Board of Nursing, Florida Administrative Code. Rule 64B states: If an applicant has been convicted or found guilty of, or has entered a plea of nolo contendere to, regardless of adjudication, any offense other than minor traffic violation, the applicant shall submit arrest and certified court records stating the nature of the offense and final disposition of the case so that a determination can be made by the Board whether the offense relates to the practice of nursing or the ability to practice nursing. I have read and understand the above statement. LAST: FIRST: XID #: Signature 2 Date

5 LSSC NURSING DEPARTMENT ADMISSION APPLICATION 2016 LAST: FIRST: XID #: GENERAL (Preferred) and BRIDGE APPLICANTS ONLY 5a. ACADEMIC COURSE COMPLETION** PROVIDE Spring Semester End Date (non LSSC courses) Course Term/Year Institution Anatomy & Physiology I w/lab (BSC 2093 & BSC 2093L) Anatomy & Physiology II w/lab (BSC 2094 & BSC 2094L) Microbiology w/lab (MCB 2010 & MCB 2010L) English Composition I (ENC 1101) Humanities Elective Nutrition w/diet Therapy (HUN 1201) Introduction to Psychology (PSY 2012) Psychology of Human Development (DEP 2004) Math for Health Related Professionals (MTB 1370) Math Proficiency: MAT0027/0028: check one- Test Score Course Computer Proficiency: Course Name **Do not leave any courses blank. Courses in progress, write in progress in Term/Year column. Course Substitution Submitted, write course sub in Term/Year column. GENERAL (Compressed) APPLICANTS ONLY 5b. ACADEMIC COURSE COMPLETION (Courses Must Be Complete Prior to Application) Course Term/Year Institution Anatomy & Physiology I w/lab (BSC 2093 & BSC 2093L) English Composition I (ENC 1101) Nutrition w/diet Therapy (HUN 1201) Introduction to Psychology (PSY 2012) Math for Health Related Professions (MTB 1370) Math Proficiency: MAT0027/0028: check one- Test Score Course 3

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