RN to BSN Completion Option Application for Admission

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1 RN to BSN Completion Option Application for Admission

2 APPLICATION FOR ADMISSION RN to BSN Completion Option Welcome to Bryan College of Health Sciences! Please complete this application to be considered for acceptance into the RN to BSN Completion Option Program. If you have questions as you are completing your application for admissions, please contact our office: Address: Office of Admissions Toll Free: , ext Web: bryanlghcollege.edu 5035 Everett Street Phone: Lincoln, NE Fax: Admission to Bryan College of Health Sciences is based on demonstrated evidence of academic ability. Recognizing human equality and the right of all persons to equal opportunity, every applicant is considered regardless of race, religion, gender, age, creed, color, national or ethnic origin, marital status, veteran status, disability or sexual orientation. To be considered for admission, the Admissions Office must receive the following items: Completed application form. Official College/University Transcript(s). Transcripts from institutions outside Nebraska require course descriptions, sent directly from the college, be submitted for review. For graduates of BryanLGH College of Health Sciences or BryanLGH School of Nursing, your signature on the application form provides consent for the Registrar at Bryan College of Health Sciences to forward an official copy of your undergraduate transcript to the Admissions Office. A copy of your Nebraska RN License. Three references, on enclosed forms, completed by individuals who are not relatives (i.e., teachers, employers, co-workers, clergy, mentors or advisors). We recommend providing each reference with a self-addressed, stamped envelope to return the Reference Form to the College. Qualified applicants will be offered an interview once the above required items are on file. $50 non-refundable application fee. Application Instructions Application Deadlines: The RN to BSN Completion Option program runs on rolling admissions. There is no specific deadline. Classes enter at Fall and Spring terms. Mission & Diversity Statement Bryan College of Health Sciences Our Mission: To provide education in the health professions emphasizing clinical and academic excellence through collaboration with Bryan Health and the health care community. Diversity Statement: Bryan College of Health Sciences honors cultural differences and promotes equality of all individuals through creation of a campus climate of inclusion, tolerance, and respect. The College provides students with curricular and co-curricular opportunities to help them to grow personally and professionally and to prepare them to be culturally competent citizens in a diverse and ever-changing society. The College emphasizes the significance of providing faculty and staff with educational and collegial opportunities to maintain an environment which recognizes the importance of cultural competence. Incomplete applications and application materials will be retained for one year after the date received.

3 Bryan College of Health Sciences RN to BSN Completion Option Application Student Information Legal Name: Last First Middle Other name(s) which may appear on records Preferred Name: Birth Date: / Gender: Male Female Current Address: City: State: Zip: Current Telephone: ( ) Cell Phone: ( ) May we text you? Yes No Permanent Address: City: State: Zip: Permanent Telephone: ( ) Work Phone: ( ) Address: Are you a U.S. citizen? Yes No If no, are you a premanent resident: Yes No Were you referred to Bryan College of Health Sciences? No Yes, by whom: Semester and year applying to: Fall: Spring: Month Day Only complete if we may call you at this number. If Yes, provider Education COLLEGE/UNIVERSITY: Please list all institutions attended. (If additional room is needed, please attach a separate sheet.) An official transcript must be sent directly from each institution. College/University City State Dates Attended Major/Degree (month/year) Completed Are you eligible to return to all collegiate institutions previously attended? Yes No If no, please attach a statement of explanation, signed and dated. Employment Employment: Please list all employment experiences, full and part-time. (If additional room is needed, please attach a separate sheet.) Title/Position Employer City State Dates Employed (month/year) Incomplete applications and application materials will be retained for one year after the date received.

4 References List the names, addresses and phone numbers of three professional or educational references, that are not friends or relatives, who can provide accurate information about you. Please provide them with the enclosed reference forms. 1. Name: Position/Title: Address: City: State: Zip: Phone: ( ) 2. Name: Position/Title: Address: City: State: Zip: Phone: ( ) 3. Name: Position/Title: Address: City: State: Zip: Phone: ( ) Criminal Background Check A criminal background check will be completed on all incoming students. Prior conviction of a felony or certain misdemeanors, other than minor traffic offenses, may make a student ineligible to participate in various clinical experiences and may make it impossible for a student to complete the program of study. Prior conviction of a felony or certain misdemeanors may make the individual ineligible for professional licensure, certification or registration. If a student is convicted of a felony or misdemeanor, other than minor traffic offenses, while enrolled in the College, it is the student s responsibility to inform the Dean of Students immediately. Any false statements made by the applicant at any time throughout the application process, or refusal to submit to a criminal background check, will disqualify the applicant. Have you ever been convicted of a felony or misdemeanor other than traffic violations? Yes No If yes, please attach a statement of explanation, signed and dated. Certification I do hereby certify that to the best of my knowledge the information furnished in this application is true and complete without evasion or misrepresentation. I understand that if found to be otherwise, it is sufficient cause for rejection or dismissal. Applicant s Signature: Date: All applicants must attach a $50 non-refundable check or money order payable to Bryan Medical Center. To avoid delay in notification of admission status, please contact the Admissions Office immediately with any change in your name, address, or phone number. Return this form and $50 non-refundable application fee to: Bryan College of Health Sciences Attention: Admissions Office 5035 Everett St. Lincoln, NE Form 1147d (Rev. 08/12)

5 Reference Form for RN to BSN Completion Program To be completed by applicant: Name of applicant: Address: City: State: Zip: Phone: ( ) Other name(s) which may appear on records: RELEASE: Under the Family Education Rights and Privacy Act, enrolled students have the right to inspect their files upon request. In order to inform the person you have requested to complete this reference form whether the form will be held in confidence or if the letter will be open to your inspection, please check one of the following statements. Waiving your rights to see this form is not a requirement for admissions. I do hereby waive my right to access this reference form. I do not hereby waive my rights to access this form. Applicant Signature: Date: Please return by: To be completed by reference: Reference name: Date: (please print) Relationship to applicant: How long have you known the applicant: How well do you know the applicant? Very well Somewhat well Not well 1. Ability to work with people 2. Leadership 3. Integrity 4. Self-direction 5. Concern for others 6. Accountability for nursing practice 7. Ability to use critical thinking skills 8. Ability to incorporate standards of care into nursing practice 9. Ability to provide holistic care for others If rated below average, please comment: Excellent Good Average Below Average No Basis for Judgment

6 Indicate any significant limitations for success in the RN to BSN Completion program: Special abilities for success in the program: Please indicate your level of endorsement for the suitability of the candidate for the program: Endorse with enthusiasm Endorse Do not endorse Please explain: Signature: Date: Position/Title: Address: City: State: Zip: Phone: ( ) Please send to: Bryan College of Health Sciences Attention: Admissions Office 5035 Everett St. Lincoln, NE bryanlghcollege.edu This reference is valid for one year after the date received. Form 1195d (Rev. 08/12)

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