Pearl River Community College Nursing Assistant Program 5448 U.S. Hwy 49 South Hattiesburg, MS 39401

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1 Pearl River Community College Nursing Assistant Program 5448 U.S. Hwy 49 South Hattiesburg, MS Instructor: Mrs. T. Camille Killough, RN, BSN Phone: Thank you for your interest in the Nursing Assistant program. The following is a list of important information about the program. If you wish to be considered for the program, please complete the attached application and return all information to the school to Mrs. Killough ONLY!!! Regular tuition assistance, such as Pell grants and student loans, are NOT available for the Nursing Assistant program. If you are interested in tuition assistance, please contact your local Pearl River Valley Opportunity (PRVO to see if you qualify for a grant or scholarship. You must contact PRVO in addition to PRCC if you would like to apply for this assistance. This is NOT the responsibility of the instructor. INFORMATION: Day Class: This is a 3 week program Classes are Monday through Friday 8:30 am- 3:00 pm Clinical days start at 7:00 am Students must be 18 years or older to gain employment If you do not have a high school diploma or GED, you may still take this class. (Speak with the instructor for further instructions You must be able to sign and have notarized an Affidavit stating that you have NEVER been CONVICTED of or plead NO CONTEST to a felony crime. Once you have completed and returned the application, you will be contacted concerning the above mentioned affidavit. SUMMER: Monday-Thursday classes from 0800 AM-4:00 PM Evening Class: Not offering at this time!!!! This is a 10 week program Classes meet on Tuesday and Thursday only Class times are from 4-8 pm All other day class information does apply Expenses: Tuition and Insurance is $ paid directly to PRCC prior to your class starting. Appropriate verification of payment must be presented to the instructor before class. This fee includes your state testing fee for the NACES state exam. Uniform-Approximately $35-$40 at uniform stores in town. The one-step TB skin test-approximately $30 at the health department or you may see your personal physician. Must have a copy of the completed test results for review by the instructor before you will be assigned a start date for the class. The process can take up to a week to complete. To Obtain an acceptance letter and be placed in an available class you must: Fill out an application, including the date you wish to start and return to PRCC/Hattiesburg Campus/C.N.A. program in Building #2 room 101 Read, sign and have notarized the appropriate background information and return to PRCC C.N.A. program Complete the (one-step) TB skin test and return the results to the PRCC/Hattiesburg Campus/C.N.A program

2 Pearl River Community College 2014 C.N.A Class Schedule at a Glance Tentative Class Start and End Dates 2014 Schedule January 13, 2014 to January 31, 2014 February 3, 2014 to February 21, 2014 February 24, 2014 to March 21, 2014 (Spring Break Holiday March 10-14) March 24, 2014 to April 11, 2014 April 14, 2014 to May 2, 2014 May 5, 2014 to May 23, 2014 Mrs. Killough s vacation May June 2, 2014 to June 20, 2014 June 23, 2014 to July 11, 2014 July 14, 2014 to August 1, 2014 August 4, 2014 to August 22, 2014 August 25, 2014 to September 12, 2014 September 15, 2014 to October 3, 2014 October 6, 2014 to October 24, 2014 October 27, 2014 to November 14, 2014 November 17 to December 12, 2014 (Thanksgiving Holidays November 24 to 29) ****Just because classes are full we are still taking applications for waiting list spots. Students who do NOT have a completed application are NOT scheduled. Students who have submitted a completed application can always apply for a waiting list spot for any of our classes. ****The WIN Center has notified me that there are NO WIA funds available for students in the nurse aide program. They will NO longer be funding students in the nurse aide program.

3 Pearl River Community College Application for Admission Today s Date 20 Social Security Number Name: Last First Middle Other Names Used Address: City State Zip Code County Phone (Day) (Home) (Other) Date of Birth Sex Race * *Confidential information requested on a voluntary basis. Refusal to provide this information will not subject the applicant to any adverse treatment, and the information will used in a manner consistent with applicable Civil Right Laws. Citizen of U.S.? Yes No address Person to be notified in case of emergency: Name (Last, First, Middle): Relationship City: State Zip Code: Phone Number In what field do you plan to major? Which Campus do you plan to attend? Poplarville Hattiesburg Other A.A (Academic) A.A.S. (Technical) Certificate (Career) Non Degree When do you plan to enter PRCC? Fall Spring Summer Year High school attended Date of graduation GED (Specify State) (Specify State) Have you previously attended PRCC? Yes No Dates: Name used: All students please complete the following section for colleges or universities that you have previously attended: Name of Institution Dates of City State Credits Degree Attendance Earned Earned Have you taken the A.C.T.? Yes No When Did you have your scores sent to PRCC? MO/Yr Yes No

4 Pearl River Community College requires applicants to answer the question: Have you ever been convicted of a felony? and Have you ever been expelled and/or dismissed from another college or university for disciplinary reasons? An applicant who answers yes will be required to submit additional information and schedule a meeting with the Dean of Student Services. The College reserves the ultimate decision on acceptance or rejection of any application. Applicants should also be aware that an individual with a felony conviction may not be able to obtain licensure in certain professions. In such cases where a felony conviction will prevent the student from applying for state licensure in a specific area, the student will be denied admission to that specific program. Have you ever been convicted of a felony? Yes No Have you ever been dismissed from another college or university for disciplinary reasons? Yes No If you answer yes to either question, contact the Dean of Student Services to schedule an appointment for an interview. ( ) An official transcript of all previous work must be received in the Admissions Office before a student is officially accepted. Return to: ADMISSIONS OFFICE, BOX 5559, POPLARVILLE, MS The Poplarville Admissions phone number is (601) If applying to our Forrest County Center, please send Application, transcripts, and ACT scores to: PEARL RIVER COMMUNITY COLLEGE, FORREST COUNTY CENTER, 5548 U.S. HWY 49 SOUTH, HATTIESBURG MS, The Forrest County Center Admissions phone number is (601) Pearl River Community College offers equal educational and employment opportunities to all persons without regard to sex, race, religion, color, national origin, handicap, or age. I AGREE THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND THAT DELIBERATE FALSIFICATION OF INFORMATION MAY RESULT IN DENIAL OF ADMISSION TO P.R.C.C. AUTHORIZATION FOR MEDICAL PROCEDURES Student Signature In the event of serious illness or accident, every effort will be made to contact parents or guardian if student is under age 21. In the event that delay in medical, surgical, or psychological treatment might be detrimental to the health of the student, authorization for consultation and treatment is required. Permission is granted Pearl River Community College to refer this student for necessary treatment. Date Signature of students (age 21 and over) Date Signature of parents or guardian (If under age 21) Address and Phone No.

5 Criminal History Record Check Information as it Pertains to Students at Pearl River Community College For the purpose of fingerprinting and criminal background history checks, the term affidavit means the use of Mississippi State Department of Health (MSDH) Form # 210, or a copy thereof, which shall be placed in the individual student s file. A person signing an Affidavit must affirm that they have NEVER been convicted of nor plead no lo contender (no contest) to any felony, including, but not limited to the following: 1. Possession or sale of drugs 2. Murder 3. Manslaughter 4. Armed robbery 5. Rape 6. Sexual battery 7. Sex offense listed in Section , Mississippi Code of Child abuse 9. Arson 10. Grand larceny 11. Burglary 12. Gratification of lust 13. Aggravated assault 14. Felonious abuse and/or batter of vulnerable adult If a person signs the affidavit required, and it is later determined that the person actually had been convicted of or pleaded guilty or no lo contendere (no contest) to any of the offenses listed herein, and the conviction or plea has not been reversed on appeal or a pardon has not been granted for the conviction or plea, the person is guilty of perjury as set out in Section , Mississippi Code of The licensed facility and Pearl River Community College shall immediately institute termination proceedings against the student pursuant to the facility s policies and procedures. Pearl River Community College may, at any time, request a background check at the student s expense. If the Student is unable to pass the background check; they will be unable to participate in the clinical training required For completion of the program, therefore, student will unable to complete the program. Definitions Possession or Sale of Drugs: Found guilty of having, holding, or selling of illegal substances Murder: The unlawful killing of a human being by another with malice aforethought, either expressed or implied Manslaughter: The unlawful killing of another without malice, either expressed or implied; which may be either voluntarily, upon a sudden heat, or involuntarily but in commission of some unlawful act Rape: Forced intercourse without consent Sexual Battery: Hitting or touching a person on his/her clothes or anything he/she is holding in way that indicates sex or sex acts

6 Definitions Continued- Arson: The malicious burning of one s own property or another s with intent to defraud or prejudice an insurer thereof Burglary: The breaking and entering the house or property of another with intent to commit a felony therein, whether the felony be actually committed or not Felony: a crime more serious than a misdemeanor Felonious: of the nature of or referring to a felony Felon: Someone guilty of a felony/has a felony conviction Felony Possession or sale of drugs: Found with having; holding, or making sale of some illegal drug in an amount as to result in a felony Armed Robbery: To take property from a person with force and use of some type of weapon. Grand Larceny: Theft of item(s) valued over $ Burglary: The act of breaking into a place for the purpose of stealing Aggravated assault: An unlawful threat to use force against another which causes them to be fearful. Felonious abuse or Battery of a Vulnerable Adult: To attack, use force or blows against a person who is elderly or above age 65 or against a person over age 18 with mental or physical disabilities and infirmities who is unable to fend off an attacker. Further includes any adult residing in a long term care facility Carnal knowledge: sexual knowledge/information about sex Unnatural Intercourse: sex acts not accepted as normal Adultery: Voluntary sexual acts between unmarried persons Fornication: Sexual acts between unmarried persons Kidnapping: To take away and hold by force Intent to Ravish: Attempt to rape Enticing a child: Offering something to a person under 18 years of age in order to cause them to cease resistance. Prostitution: The act of offering sex or sex acts for money Gratification 0f Lust: Touching a person, usually a child, under age 18 for lustful or sexual purpose Dissemination of sexually oriented material: Distribution of sexually oriented/ graphic material to material to persons under 18 years of age Exploitation of children: To use a person under 18 years of age for ones own selfish ends Child Abuse: Conduct toward an emancipated child under 18 years of ages by the parents, guardian, or other Person, who cares for, has custody of or authority over the child. There are four degrees of abuse: First Degreeoccurs when the defendant knowingly or intentionally causes serious physical or mental abuse. Second Degree- Occurs when the defendant willfully abandons the child, fails to provide food, clothing or shelter necessary for The child s welfare, or commits a reckless act which results in serious physical or mental harm. Third Degreeoccurs when the defendant knowingly or intentionally causes some physical harm to the child. Fourth Degreeoccurs when the defendant abandons the child, or willfully fails to provide food, clothing or shelter necessary for the child s welfare, or commits a reckless act, which results in some physical harm to the child. I have read the above information and it has been explained to me. Printed Name: Signature: Date:

7 PEARL RIVER COMMUNITY COLLEGE HEALTHCARE CRIMINAL HISTORY BACKGROUND AFFIDAVIT State of Mississippi Before me, a Notary Public in and for the County of and State aforesaid, personally appeared the undersigned who, After being by me duly sworn did state upon his/her oath as follows: a. That the affiant is currently enrolled at Pearl River Community College in a healthcare professional/vocational Technical Academic program or is an applicant for such program b. That the affiant has not been convicted of or pleaded guilty or no lo contendere to a felony of possession or sale of drugs, murder, manslaughter, armed robbery, rape, sexual battery, sex offense listed in Section (f), Mississippi Code of 1972, child abuse, arson grand larceny, burglary, gratification of lust; aggravated assault; or felonious abuse and/or battery of a vulnerable adult; that has not been reversed on appeal or for which pardon has not been granted. c. That the affiant understands that a fingerprint/background check may be required at any time by Pearl River Community College in accordance with section of the Mississippi Code and any information gained through such query that indicates a conviction of any of the offences listed above will result in termination of enrollment. d. The affiant also understand that any future background checks conducted by licensure boards or employers which yields information pertaining to conviction of those crimes listed above as well as others may cause said licensure board or employer to refuse licensure or employment. Name of Affiant (Printed) Signature of Affiant SWORN TO AND SUBSCRIBED BEFORE ME, this day of, 20 Signature of Notary Public My Commission Expires