PRACTICAL NURSING APPLICATION FOR ADMISSION

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1 PRACTICAL NURSING APPLICATION FOR ADMISSION Application Instructions: 1. Complete the entire application in ink (Please print or type). Full Legal Name Address City, State, Zip Last First Middle Maiden 2. Attach the deposit of $100 payable to Portage Lakes Career Center. 3. Return the application And deposit to: P.L.C.C.-PN Program 4401 Shriver Rd Uniontown, OH If you have questions, call: Schedule your pre-admission WorkKeys assessment by calling Kim Robinson at: Primary Phone ( ) Secondary Phone ( ) Address Social Security Number Place of Birth (City, State, County, Country) Citizenship Name of High school: City & State: Date of Graduation: Date of Birth United States Other immigration status (attach copy of documentation) Alien lawfully admitted for permanent residency in the United States (attach copy of front and back of alien registration card) 6. Application does not guarantee admission. GED Testing Location: Date Passed: Post Secondary, technical schools, colleges or universities and/or Nursing Programs* attended: If you have previously attended another nursing school (not pre-nursing course) please call the coordinator for information about required paperwork. Institution Address Reason for leaving The Portage Lakes Joint Vocational School District is an equal opportunity educational institution. Employment and educational programs are offered without regard to race, color, religion, national origin, gender, disability, military status, ancestry, age, genetic information or any other legally protected characteristic. The district prohibits harassment of individuals in any form. Concerns of possible discrimination or harassment should be referred to Mr. Michael Kaschak, Compliance Coordinator, at I understand that making application for admission to the Portage Lakes Career Center-W. Howard Nicol School of Practical Nursing places no obligation upon me or the school with regard to my admission until such time as I might be accepted for admission. I certify that all statements made on this page of this application are true. Signature Date

2 Portage Lakes Career Center W. Howard Nicol School of Practical Nursing Background Information The following is information that is required by the school, its clinical sites and/or the Ohio Board of Nursing for licensure. It is our desire to make you aware of this information prior to making any financial commitment to the program. If you respond yes to any of these questions, need clarification, or have concerns about these questions, please contact the program s coordinator. 1. Have you ever been convicted of, found guilty of, pled guilty to, pled guilty to by reason of insanity, entered an Alford plea, received treatment or intervention in lieu of conviction, or received diversion, for any reason, of the following crimes (this includes crimes that have been expunged or sealed). a. A felony in Ohio, another state, commonwealth, territory, province, or country? YES NO b. A misdemeanor in Ohio, another state, commonwealth, territory, province, or country? YES NO (This does not include traffic violations unless they are DUI/OVI). If you answered yes to either question, you are required to provide the school with a written explanation of the events including the date, county, and state in which the events occurred. Attach a separate sheet to the application. Also submit a certified copy of the indictment, plea and journal entry from the appropriate court for each offense. A copy of the court docket or case summary does not meet this requirement. 2. Have you ever been found to be mentally ill or mentally incompetent by a probate court? YES NO If you answered yes, you are required to provide the school with a written explanation of the events including the date, county, and state in which the events occurred. Attach a separate sheet to the application. 3. Has any board, bureau, department, agency or other public body, including those in Ohio, in anyway limited, restricted, suspended, or revoked any professional licensure or certificate granted to you, placed you on probation, imposed a fine, censure, or reprimand against you? YES NO Have you ever voluntarily surrendered, resigned, or otherwise forfeited any professional license, certificate or registration? YES NO 4. Have you ever, for any reason, been denied an application, issuance, or renewal for license/certification or privilege of taking examination, in any state (including Ohio), commonwealth, territory, province, or country? YES NO 5. Have you ever entered into an agreement of any kind, whether oral or written, with a respect to a professional license or certification in lieu of or in order to avoid formal disciplinary action with any board, bureau, department, agency, or other public body, including those in Ohio? YES NO 6. Have you ever been notified of any current investigation of you or have you been notified of any formal charges, allegations, or complaints filed against you by any board, bureau, department, agency, or other public body, including those in Ohio? YES NO 7. Have you ever been diagnosed as having or have you been treated for pedophilia, exhibitionism, or voyeurism? YES NO

3 8. Within the last five years, have you been diagnosed with or have you been treated for bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder? YES NO 9. Have you, since attaining the age of eighteen or within the last five years, which ever period is shorter, been admitted to a hospital or facility for the treatment of bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder? YES NO 10. Are you currently engaged in the illegal use of chemical substances or controlled substances? YES NO For the purposes of this question currently does not mean the day of or even weeks or months preceding the completion of this application. Rather, it means within the last two years or recently enough so that the use of drugs may have an ongoing impact on one s functioning in the delivery of safe patient care. Illegal use of chemical substances or controlled substances means the use of chemical substances or controlled substance obtained illegally (for example; marijuana, heroin, cocaine, or methamphetamine) as well as the use of controlled substances which are not obtained with a valid prescription or not taken in the accordance with the direction of a licensed healthcare provider. a. If you answered yes to question 10, are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you in order to assure that you are not illegally using chemical substances or controlled substances? YES NO If you answered yes, you are required to provide a written explanation. If you are participating in a monitoring program, you are required to have the program provide information detailing your participation in and compliance with the program. 11. Have you been notified of any proceeding to determine whether you may be subject to listing on the Sexual Civil Child Abuse Registry established by the Ohio attorney general pursuant to section of the Ohio Revised Code and/or are you listed on that registry? YES NO Please review the Criminal Record Policy enclosed in this packet. If any question is unanswered the application will be returned to you for completion. I certify that all statements made on this page are true. Signature Date

4 PORTAGE LAKES CAREER CENTER W. HOWARD NICOL SCHOOL OF PRACTICAL NURSING STUDENT HANDBOOK DRUG AND ALCOHOL POLICY All students will undergo a drug screen by urine test prior to or at the time that the program begins. Students must submit a urine sample within two (2) hours of the time requested. This test will be conducted by an independent agency contracted with the school. All results will be confidentially reported to and become property of the school. Blood alcohol levels or breathalyzer tests may also be required. Results that show dilute urine will require a retest at a date and time scheduled by the school. Portage Lakes Career Center W. Howard Nicol School of Practical Nursing has a zero tolerance policy regarding the use of illegal drugs and the abuse of alcohol and/or prescription drugs. Students are required to be free from the use and appearance of use of alcohol and drugs while in class, lab, and clinical experiences. The safety of any client, student, and staff require that anyone using illegal substances be removed from the program. Random drug screens will be conducted with or without cause during the course of the program. The faculty has the right and responsibility to remove students from the classroom and/or clinical site if the student s behavior presents a concern for client safety. Students who have been removed from the educational setting will be required to have an immediate drug and alcohol screen done at the facility of the school s choice. Students will be advised against operating a motor vehicle. In the interest of safety, local authorities will be notified if students do so. Students who have a positive drug screen for prescription drugs are required to submit the prescription bottle to the Coordinator of the program at the beginning of the next school day. Failure to submit the requested prescription will result in a recommendation for immediate dismissal from the program. Students who test positive for illegal substances or legal substances for which they have no prescription will be recommended for immediate termination from the program. Students terminated for the reasons noted above forfeit readmission to the program. Students are required to disclose any history of alcohol and/or drug abuse/addiction to the Coordinator prior to beginning the program. Possession, distribution or sale of alcohol or any illegal, illegally obtained or prescription drug at the school or at any affiliation, observation site, or school function will result in a recommendation for immediate dismissal. The cost of all drug and alcohol screenings, assessment and evaluations, counseling and or treatment is the responsibility of the student. The student will be advised to see a chemical assessment counselor, have an assessment done, and follow the recommendations of the counselor. The applicant/student who currently, or within the past two (2) years, is participating in a program monitoring for drug and/or alcohol use, is in rehabilitation, treatment or a professional assistance program must provide the Coordinator with detailed information detailing participation and compliance with the program. My signature indicates that I have read and understand this policy. Signature: Date:

5 PORTAGE LAKES CAREER CENTER W. HOWARD NICOL SCHOOL OF PRACTICAL NURSING CRIMINAL RECORD POLICY This policy serves to protect the clients, students and staff of Portage Lakes Career Center and Clinical Affiliation sites. The safety and well- being of the patients, for whom care is provided, is our primary consideration. All students will have an Ohio and FBI criminal records check done prior to or at the start of the program. Fingerprinting for the criminal records check will be done at Portage Lakes Career Center. The Ohio Bureau of Criminal Identification and Investigation will conduct the criminal records check. The results of the records check will be sent to the Career Center and become the property thereof. Students are not permitted to participate in clinical experiences until their report is received. Students may be denied access to clinical sites due to criminal record(s). Students who have failed to disclose any criminal records on their application will be immediately terminated from the program for falsification of the application. Students who have a criminal charge occurring between the time of application and the first day of attendance must disclose the charge immediately. The Ohio Board of Nursing must, by law, refuse licensure to a person whose record indicates that the person has pled guilty to, been convicted of or has had a judicial finding of guilt for committing Aggravated Murder, Murder, Voluntary Manslaughter, Felonious Assault, Kidnapping, Rape, Sexual Battery, Gross Sexual Imposition, Aggravated Burglary, or a substantially similar law of another state or country. For this reason a person who has such a criminal record will not be admitted to the program. Persons having other criminal records may be, by law, barred from employment in pediatric and adult care facilities. The clinical sites with whom the school is contracted require that the students meet the same criteria as employees. The crimes included are: Records with a pending disposition or outstanding warrant, three or more misdemeanor convictions, two or more DUI convictions or misdemeanor marijuana convictions, failure to appear in court, all convictions involving: violence, weapons, controlled substances, sexual activity, theft, dishonesty, burglary, and crimes against children. In addition, felony convictions for the following crimes: forgery, conspiracy to commit arson, aggravated assault, robbery, welfare or medical fraud, falsification to law enforcement, passing bad checks (more than one), possession of a concealed firearm, aiding a prisoners escape, patient abuse or neglect, insurance fraud, receiving stolen property, drug abuse, vehicular homicide, misuse of credit cards, contributing to the delinquency of a minor, and extortion. Dispositions of not guilty, waiver by clerk or magistrate, adjudication withheld, or dismissed are permissible. Traffic violations are permissible.

6 Conviction of any of the following charges will exclude students from enrolling at Portage Lakes Career Center: Abduction Aggravated Arson Aggravated Burglary Aggravated Murder Child Enticement Child Stealing Compelling Prostitution Corruption of a Minor Counterfeit Drug Offenses Deception to Obtain Dangerous Drug Deception to Obtain Matter Harmful to Juveniles Dissemination or Displaying Matter Harmful to Juveniles Endangering Children Felonious Assault Felonious Sexual Penetration Funding of Drug or Marijuana Trafficking Gross Sexual Imposition Illegal Conveyance or Possession of Deadly Weapon or Counterfeit Firearm into a School Safety Zone Illegal Dispensing of Drug Samples Illegal Manufacture of Drugs or Cultivation of Marijuana Illegal Use of Minor in Nudity-Oriented Material or Performance Improperly Discharging a Firearm At or Into a School Improperly Furnishing Firearms to a Minor Intimidation of Public Servant or Witness Kidnapping Loitering to Engage in Prostitution Murder Pandering Obscenity Involving a Minor Permitting Child Abuse Placing Harmful Objects in Food or Confection Possession of Hoax Weapon of Mass Destruction Promoting Prostitution Prostitution Rape Reckless Homicide Retaliation Against Public Servant or Witness Riot Robbery Sexual Battery Sexual Imposition Soliciting or Supporting Terrorism Trafficking in Drugs Trafficking in Harmful Intoxicants Unlawful Possession of Explosives Voluntary Manslaughter Applicants with any other criminal records are required to submit certified copies of the Indictment, Plea and Journal Entry for each offense with their application. The applicant will be counseled regarding admission, clinical site availability, potential for employment and licensure. Students will be fingerprinted a second time six to eight weeks prior to graduation. The results of the BCI & FBI criminal background check will be sent to the Ohio Board of Nursing and the school. Students with criminal records will be subject to the above stated policy. Criminal Offenses, in addition to those listed above that Preclude Admission to the Practical Nursing Program Reckless Homicide, Abduction, Child Stealing, Child Enticement Disseminating, and Displaying Matter Harmful to Juveniles Dispositions of not guilty, waiver by clerk or magistrate, adjudication withheld or dismissed are permissible. Traffic violations are permissible. My signature indicates that I have read and understand this policy. Signature: Date:

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