LVN PROGRAM APPLICANT CHECK LIST

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1 LVN PROGRAM APPLICANT CHECK LIST Download Information Packet and read thoroughly Application packet Completed all college admission requirements (see catalogue) Register for TEAS in the Testing Center (first floor) TEAS review book in library or BC Bookstore Complete application packet by July 30, 2015 All prior and current transcripts must be submitted to the college registrar. All transcripts must be received by Brazosport College Registrar prior to turning in application. Applicants are entirely responsible for ensuring transcripts are received in Registrar s Office. References: are best from professors or anyone who can objectively evaluate your academic ability. (references from friends or co-workers are not as strong) Seek references in advance! Do not wait until the submission deadline. It is recommended to provide professors plenty of time to complete a form. Begin required vaccinations (if pursuing a career in Health Professions) especially Hepatitis B (3 shot series). The local Texas Department of Health is usually least costly. TDH locally administers Hepatitis B and other vaccinations. The Health department administers vaccinations on specific days only. Call the local DTH office before you go to insure needed vaccines are on hand. Angleton: ; Clute: Keep your contact information current. If we cannot contact you, you will miss an opportunity Applicants are responsible for submitting ALL application materials Keep your own checklist of submitted documents May 1, 2015 July 30, 2015 May 2015 July 2015 Application Period Timeline Applications available TEAS Testing (see flyer for all dates and times) in TESTING CENTER

2 BRAZOSPORT COLLEGE NURSING PROGRAM APPLICATION FOR ADMISSION Print clearly in ink, please answer all questions (Name) Last First Middle Initial (Indicate if NONE) (Mailing Address) Street City State Zip (Residence If Different) Street City State Zip *Social Security Number: Are you 18 years of age or older? (circle) YES NO Phone Numbers (include area code): Home Cell Other Emergency contact: Name, contact info, and relation to you OPTIONAL DEMOGRAPHIC DATA Demographic data is reported as group, anonymous information only. Providing or omitting demographic data does not influence applicant, interview, program, or student decisions. Ethnicity (Choose One) Caucasian (Non-Hispanic) Caucasian Hispanic African American American Indian Asian Indian Sub Cont Other: Gender (Choose One) Male Female Age Range (Choose One) Self-Defined Economic Status Yearly Household Income (Choose One) <18,000 18,000-23,999 24,000-39,999 30,000-35,999 36,000-42,999 43,000 49,999 50,000+ Marital Status (Choose One) Single Divorced Separated Married Widowed Other EDUCATION (Begin with current or most recent include all secondary institutions attended) Institution name and address Dates Attended Degree or Certificate If Appropriate Professional Education or Certificates List all past and current professional licenses, certificates, registrations, or any clinical/patient experience Past or Prior Nursing School Attendance Have you attended or attend any schools of nursing? YES NO If yes, fully explain and describe reasons for withdrawing, academic standing, name and address of school and contact person: SEE ADMISSIONS INFORMATION SECTION #6. (can use separate paper)

3 The application for the Vocational Nursing Program includes five questions applicants must answer during the licensure application process. Information provided is mandated by the Texas Board of Nursing (TBON) as part of the licensure process in Texas. Students with concerns regarding issues addressed in the questions should review the applicant information packet for clarification. Certain situations may allow an individual to answer no to a question even though there is a positive history. Individuals may complete the program and have licensure denied or revoked due to extenuating circumstances related to issues addressed in the questions. This information is provided to make applicants aware of real or potential eligibility issues affecting licensure after completing the eleven month LVN program. For further information or questions, you may contact the Texas Board of Nursing at (512) or visit the website at: The Texas Board of Nursing provides extensive public information about eligibility and appeal of eligibility for licensure. The board has a published appeal process that may require as long as 18 months to complete. A prior condition, problem, legal issue, health issue, or other specific incident or occurrence may NOT affect eligibility. Failure to proactively enter the declaratory board order process will delay or prohibit eligibility status. The Declaratory Order Form is available on the TBON website. You will be asked the following questions during the last program semester. All applicants undergo an FBI criminal background check, including fingerprints. If you answer yes at that time to any of the questions (below) you may, under certain conditions, ineligible for the NCLEX-PN Examination. If you have questions, call the Director of Vocational Nursing, Janena Norris at (979) , or Mrs. Norris at 1) [ ] No [ ] Yes For any criminal offense, including those pending appeal, have you: A. Been convicted o a misdemeanor? B. Been convicted of a felony? C. Pled nolo contendere, no contest, or guilty? D. Received deferred adjudication? E. Been placed on community supervision or court-ordered probation, whether or not adjudicated guilty? F. Been sentenced to serve jail or prison time? Court-ordered confinement? G. Been granted pre-trial diversion? H. Been arrested or have any pending criminal charges? I. Been cited or charged with any violation of the law? J. Been subject of a court-martial; Article 15 violation; or received any form of military judgment/punishment/action? (You may only exclude Class C misdemeanor traffic violations.) NOTE: Expunged and Sealed Offenses: While expunged or sealed offenses, arrests, tickets, or citations need not be disclosed it is your responsibility to ensure the offense, arrest, ticket or citation has, in fact, been expunged or sealed. It is recommended you submit a copy of the Court Order expunging or sealing the record in question to our office with your application. Failure to reveal an offense, arrest, ticket or citation that is not 7 in fact expunged or sealed, will at a minimum, subject your license to a disciplinary fine. Non-disclosure of relevant offenses raises questions related to truthfulness and character. NOTE: Orders of Non-Disclosure: Pursuant to Tex. Gov t Code (b), if you have criminal matters that are the subject of an order of non-disclosure you are not required to reveal those criminal matters on this form. However, a criminal matter that is subject of an order of non-disclosure may become a character and fitness issue. Pursuant to other sections of Gov t Dose chapter 411, the Texas Board of Nursing entitled to access criminal history record information that is the subject of an order of non-disclosure. If the Board discovers a criminal matter that is the subject of an order of non-disclosure, even if you properly did not reveal that matter, the Board may require you to provide information about that criminal matter. 2) [ ] No [ ] Yes Are you currently the target or subject of a grand jury or governmental agency investigation? 3) [ ] No [ ] Yes Has any licensing authority refused to issue you a license or ever revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, refused to renew a professional license, certificate or multi-state privilege held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you? 4) [ ] No [ ] Yes Within the past five (5) years have you been addicted to and/or treated for the use of alcohol or any other drug? 5) [ ] No [ ] Yes Within the past five (5) years have you been diagnosed with, treated, or hospitalized for schizophrenia and/or psychotic bipolar disorder, paranoid personality disorder, antisocial personality disorder, or borderline personality disorder? If YES indicate the condition: [ ] schizophrenia and/or psychotic disorders, [ ] bipolar disorder, [ ] paranoid personality disorder, [ ] antisocial personality disorder, [ ] borderline personality disorder If you answered YES to any of the questions listed above, attach a letter of explanation that is dated and signed indicating the circumstance(s) you are reporting to the Board.

4 RECOMMENDATIONS Provide complete name, title, and address of three recommendations. Applicants are responsible for copying supplied recommendation form and providing a self addressed envelope for each form. Recommendations must be completed and returned in sealed envelope directly to the ADN Program. Recommendations cannot be from relatives or persons living with you. Choose individuals who are prepared to comment on your work ethic, academic potential, character, and suitability for intense nursing education INFORMATION PACKET Please indicate that you have read and understand the informational packet regarding the current application cycle: YES NO Paste or attach a clear copy of a recent picture for identification and security purposes. Falsification by submission or omission may result in denial or dismissal. Signing this document indicates you have read and understand all materials contained in this application document. Failure to complete application documents as described here constitutes an incomplete application, which is not screened or considered. Applicants are solely responsible for submitting and ensuring completion of application materials. Brazosport College and the nursing program assume no responsibility for obtaining documents or notifying applicants of incomplete application materials. Incomplete application packets are destroyed April 30 th of each year. I certify that all the information on this application is true and correct. Applicant s Signature Date Please submit all transcripts and scores ASAP as required by the college. Students are responsible for submission of all required documents. Incomplete applications are not considered. Brazosport College does not discriminate on the basis of sex, handicap, race, creed, color, age and national origin in its educational and vocational programs, activities, or employment as required by Title IX, Section 504 and Title VI.

5 BRAZOSPORT NURSING PROGRAM Applicant Recommendation Form APPLICANT COMPLETE THIS BOX Print Applicant Name: Date: Print Name of Individual Providing Information and Relationship to Applicant: Applicant: Complete above box, supply form with a stamped return envelope addressed to: Brazosport College Division of Health Professions 500 College Drive, Lake Jackson, TX Once completed mail or deliver the sealed form in the addressed envelope. Please sign the seal of the envelope. Applicants are responsible for timely return of recommendation forms. Applicants should speak directly with individual providing reference and not the Nursing Program when inquiring whether forms have been returned. Individual completing form, circle one option in each box (circle and initial). When finished, please seal in envelope provided and sign across the seal. Thank you. I DO or DO NOT grant permission, for the completed recommendation form to be available to applicant for review. I HAVE OR HAVE NOT discussed this completed recommendation form with the applicant. This applicant is seeking admission to a professional nursing program. Professional nurses provide health care to individuals and families across the life span, during crises, joy, death, injury, and every facet of life. Nurses must be competent, compassionate, non-judgmental, and ethical. Thank you for taking the time to complete this valuable part of the application process. Please rate the applicant using the following scale. Explanatory or clarifying comments are appreciated. 1= N/A = No Basis for Judgment 2= Unsatisfactory 3 = Satisfactory 4 = Above Average 5= Outstanding Demonstrated academic success Responsible for learning Ability to cope with extended periods stress Respect for others privacy Communication Skill Working as a team member Suitability for nursing career Integrity Signature: Title: Date: Contact Information:

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