Rogue Community College. 2015/16 Nursing Program Application. For Fall 2016 Entry

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1 Rogue Community College 2015/16 Nursing Program Application For Fall 2016 Entry STEP ONE: Complete the online portion of the application available at: DO NOT submit the online portion of the form more than once. To verify whether you have already submitted the online form, your Name and RCC I.D. Number to: STEP TWO: Complete, print, and sign the Checklist and Agreement Form and the Prerequisite/Course Completion Chart. If applying for the work experience point, attach the completed Work Experience Verification Form and proof of your current unencumbered Oregon certification or licensure as a CNA, LPN, RT, EMT, Paramedic or service standing as a Corpsman or Medic. If applying for military veteran points, include a photocopy of your certified Form DD214 Service 2, verifying your honorable discharge. STEP THREE: Mail the printed forms along with the $100 non-refundable processing fee (check or money order made out to Rogue Community College) in a sealed envelope (make sure a complete return address including the applicant s name is on the outside of the envelope) to be received no later than the annual deadline of 5 p.m. on February 15, Note that since February 15, 2016 is a holiday when the College is closed, this year applications will be accepted until 5 p.m. February 16, 2016, and must arrive at the address below by that deadline. Rogue Community College, Enrollment Services Attention: Nikki Koenig, RVC-G Nursing Application 114 S. Bartlett Street Medford, OR 97501

2 2015/16 Nursing Program Application Checklist and Agreement (for Fall 2016 Entry) Applicant Name RCC Student ID Social Security Number Secure Address (Official notifications will occur by . It is the applicant s responsibility to provide a secure address and ensure the College and Nursing Program administrative assistant are notified of any changes in address.) Applicant: You must complete and submit this checklist as part of your nursing application. Please initial each statement below indicating that you have read, understand, and agree to the application requirements for the RCC Nursing Program. Initial each item below: 1. I have been officially admitted to RCC and have obtained my 7 digit RCC ID#. 2. I have already completed STEP 1 by submitting the online portion of my Nursing Program Application. 3. I have previously submitted (and verified arrival of official transcripts at RCC) or have attached sealed official college transcripts from ALL previously attended, regionally accredited colleges or universities including all coursework completed through Fall Term I understand I will not be awarded 5 points for non-repeat of A&P if I do not submit such transcripts. (Rogue Community College transcripts do not need to be attached.) 4. I understand that a minimum of 30 credits of prerequisites must be completed with a C or better by the end of Fall Term 2015 (with a minimum cumulative GPA of 3.0), including BI231 Anatomy & Physiology I with lab and MTH95 or higher level math course (or equivalent transfer courses), in order to be eligible to apply. 5. For International students only: See Enrollment Services for admissions and registration information. 6. I understand that if my points qualify me for Phase 2 as one of the top 85 applicants, I will receive an from the Nursing Program and need to respond to reserve a seat at the scheduled session (hold open dates: April 8, 9, 15, 16) in the computer lab on the Redwood Campus. If I have not received notice of my status (i.e. whether I am among the top 85 applicants or among those who do not make it to Phase 2) by April 1, 2016, I will call the Nursing Program at

3 7. I have provided a secure address on my application and give my permission for RCC to contact me through this address. I understand I will be ed a notice verifying receipt of the application packet I am submitting to RCC and that I will also receive notification of my Degree Audit results through once it has been completed. I also understand that each applicant will be notified by of his/her status regarding acceptance by June 1, I also understand that I am not to call the Nursing Program or Enrollment Services regarding acceptance status unless so directed. 8. I understand that if I have a financial hold on my RCC account, my application will be disqualified unless the financial hold is removed before 5 p.m., February 16, I understand to earn selection points for being a military Veteran I must attach proof of my honorable discharge (Photocopy of my Certified Form DD214 Service 2). 10. I understand to potentially earn a selection point for work experience (only as a CNA, LPN, RT, EMT, Paramedic, Medic, or Corpsman), I must attach a completed Work Experience Verification Form and proof of my current certification or licensure as a CNA, LPN, etc. (Medic or Corpsman work experience documentation should indicate standing at the time of service.) 11. I have completed and attached the Prerequisite/Course Completion Chart. 12. I have attached the $100 non-refundable nursing application processing fee (check or money order made payable to Rogue Community College). 13. I understand that any documents submitted, but not requested by this application form (e.g. letters of reference) will be discarded/shredded. 14. I understand that reading and following directions is critical to success in any nursing program. Incomplete applications (e.g. not completing admission to Rogue Community College, lack of student ID number in places where ID number is called for, lack of application fee, lack of submission of Official transcripts to Enrollment Services, lack of signature, etc.) will result in disqualification and that disqualified applicants will only receive notice of such after the application deadline has passed. 15. I understand applications will be accepted beginning September 28, 2015, even though fall courses have not yet been completed. I understand it is my responsibility to make sure that all required application materials are received in the RCC Enrollment Services Office (or postmarked) no later than 5 p.m. on February 16, I have read and I understand the program information and admission criteria (including requirement for negative urine drug screen and criminal history background check in order to be admitted) for the nursing program at RCC. Program information, including selection points, may be found at: I understand that if accepted I will be required to order a criminal history background check with the RCC Nursing Department s contracted agency which performs criminal history background checks and must self-disclose any pertinent history prior to admission and must disclose any warrant, arrest, citation, charge or conviction if such occurs after acceptance.

4 18. I understand that a history of certain crimes might result in my being deemed not approved for the program. 19. I understand that by making application to the Rogue Community College Nursing Program I am also applying for co-admission and authorizing the release of my application and academic information to OHSU as needed to facilitate my program of study or financial aid. 20. I understand that although co-admitted to the Oregon Health & Science University School of Nursing, if I choose to transition to OHSU, I will have to request an additional Criminal Background Check specifically for OHSU and my ability to enroll in OHSU courses may be negatively impacted by any criminal history in my background. 21. I give my permission for release of pertinent application and academic information to the OCNE partner schools, Oregon Center for Nursing, and the Oregon State Board of Nursing for statistical, research, and evaluative purposes only. 22. I understand that it is my responsibility to meet all program and application criteria. RCC staff are available to answer application related questions, but will not check my application for completeness prior to submission. 23. I verify that all statements on this application are complete and true and I understand that falsification of any information may lead to disqualification or dismissal from the program. Applicant Signature RCC Student ID Date If the applicant is less than 18 years old, a parent must also sign: In compliance with state and federal laws, Rogue Community College does not discriminate on the basis of race, religion, color, national origin, age, sex, veteran status, marital status, sexual orientation, genetic information, disability or any other characteristic protected by federal, state or local laws in employment, or in any of its educational programs or services. For information about Rogue s policy of non-discrimination, contact the Title IX coordinator at (541) or the Section 504 coordinator at (541)

5 Rogue Community College Nursing Program Prerequisite/Course Completion Chart Student Name/ID #: Complete this form to the best of your ability. It serves as a double check for the transcript specialists. To be eligible to apply, you must have completed a minimum of 30 credits of the required prerequisite/preparatory coursework including MTH95 or higher and BI231 (or equivalent within the past 7 years) with a cumulative application GPA of at least 3.0 prior to the application deadline. For calculation of your application GPA, your most recent grade in a course will be used. Exception: If you have completed more than one math, computer science or required elective course that would equally apply to a requirement, the course with a higher grade will be used. If you are accepted to the program, all prerequisite/ preparatory courses (minimum of 45 credits) must be completed with a C or better by the end of summer term in order to retain acceptance. Required Prerequisite/Preparatory Courses RCC Course Number/Title CS120 Concepts in Computing (or documented proficiency within 10 years) Your Completed or Planned Course # College & Year Course Completed (or planned course) Grade (if complete) RCC Credits BI211 General Biology I w/lab (including genetics) 4 BI231 Anatomy & Physiology I (within 7 years) 4 BI232 Anatomy & Physiology II (within 7 years) 4 BI233 Anatomy & Physiology III (within 7 years) 4 MTH95 (or 93 & 94) Intermediate Algebra or higher 4 NFM225 Nutrition 4 *PSY201 or 202 General Psychology I/II (or other 3-4 credit Social Science if PSY215 requirement has been met. PSY215 Lifespan Human Development 4 *WR121 English Composition I *4 *WR122 English Composition II *4 **Social Science Elective 3 ***Humanities, Social Science, or Science Electives (Will only be applied as needed to meet minimum of 45 prerequisite/preparatory credits) *3 credit courses completed before Summer 2009 are acceptable to meet these prerequisites. **See the College Catalog for a list of acceptable Social Science courses that meet this requirement for the AAS degree. ***Most applicants will not require additional credit in this elective area to meet the 45 credit prerequisite requirement. See the College Catalog for a list of acceptable Social Science, Humanities, and Science courses. This elective area may also include 100-level or higher foreign language, speech, or extra credits when a 4 or 5 credit course has been used to meet a 3 credit requirement. Possible Additional Selection Point Items I have previously earned an Associate s Degree or higher at a regionally accredited College/University. Please Circle Your Response Additional Information YES NO Highest Degree Completed: 0-4 *4 0-6 Completed at (School Name) I have previously completed BI234 Microbiology w/lab (or equivalent) with a C or higher grade. YES NO Term/Year Completed: I have completed at least 12 credits of in-program electives as listed on the Nursing Graduation Guide. YES NO Number of in-program elective credits completed: I have repeated BI231 or BI232 or BI233 at least once in YES NO the past 7 years. (W & AU attempts count as repeats) I am a military veteran and have submitted my DD214 as YES NO proof of my honorable discharge from the service. I have submitted the signed Work Experience Form YES NO verifying at least 400 hours of work experience as a CNA, LPN, RT, EMT, PARAMEDIC or Medic/Corpsman and I have provided proof of such certification/licensure. I am a current resident of Josephine or Jackson County YES NO

6 WORK EXPERIENCE VERIFICATION - CNA, LPN, RT, EMT, PARAMEDIC or MEDIC/CORPSMAN Rogue Community College Nursing Program 2015/16 Application for 2016 Fall Entry Student Name: Date: Dear Employer/Supervisor/Human Resources Manager: The above individual is planning to apply to the RCC Nursing program by the February 2016 deadline. To earn one point in the selection process, the applicant must prove accumulation of a minimum of 400 hours work experience since February 1, 2015 in any of the above (and only the above) roles and hold current certification or licensure. [Note: Veterans who served as a medic or corpsman must prove 400 hours of experience in that role since February 1, 2012.] To assist this applicant with the process, please fill in the requested information, seal this form in an envelope (preferably a company letterhead envelope) and sign your name across the seal. The applicant may submit documents from more than one employer in order to provide proof of required hours of work experience. The applicant must attach the sealed envelope to the application and submit it no later than 5:00 p.m. on February 16, 2016 to be eligible for the point. If you have any questions you may call me at (541) Thank you for your help. Sincerely, Linda Wagner, RN, MN Nursing Department Chair Can you verify that this applicant has worked as a (licensed) CNA, LPN, RT, EMT, PARAMEDIC, MEDIC or CORPSMAN (circle one) for >400 hours at your facility in the time frame given above? Yes No Total Number of Hours Worked here as: [ ] = Insert role Total hours Signature of Supervisor, HR Manager, or Commanding Officer Facility Printed Name and Title Phone Number

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