NURSE PRACTITIONER APPLICATION PACKET

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1 NURSE PRACTITIONER APPLICATION PACKET ADMISSIONS CONTACTS: MSN Program Director Dr. Vera Dauffenbach Administrative Assistant Nancy McCulley Bellin College Mission Bellin College is dedicated to preparing health-care professionals by providing an intellectually stimulating environment focused on leadership, community service, and lifelong learning that promotes excellence in health-care practice and the advancement of the profession. Bellin College Values Excellence being the best Integrity honest and ethical behavior Community partnership and shared participation Caring empowering relationships based on empathy and respect MSN Program Philosophy The graduate program builds on the baccalaureate nursing education to prepare nurses for leadership roles in advanced practice. The master s curriculum provides the depth and breadth of knowledge and skills that are applied in a variety of educational and clinical settings. Role development and scholarship that attend to leadership and professional standards provide the foundation for advance practice. The Master of Science in Nursing program provides a foundation for doctoral study. Program Descriptions Graduates of Bellin College master s degree programs in nursing are prepared with broad knowledge and practice expertise that build and expand on baccalaureate nursing education. This preparation provides graduates with a deeper understanding of nursing in order to engage in advanced practice and leadership in a variety of settings and commit to life-long learning (AACN, 2010). Family Nurse Practitioner The Family Nurse Practitioner track is a 48-credit program designed to prepare graduates to function as license independent practitioners. Students complete core coursework followed by courses that focus on the provision of the full spectrum of health care services across the lifespan. Students learn to use advanced health assessment skills, screening and diagnostic strategies along with prescriptive practices to manage the health/illness status of patients and families. Practicum experiences that total 680 hours are completed in varied health care and community settings. Graduates are eligible to take ANCC and/or AANP Family Nurse Practitioner certifying exams.

2 Accreditation The College is accredited by the Higher Learning Commission (HLC) of the North Central Association of Colleges and Schools. The Bellin College BSN and MSN Programs are approved by the Wisconsin Board of Nursing and the Commission for Collegiate Nursing Education (CCNE) through APPLICATION PROCESS Applicants are required to complete the following to be considered for admission: 1. Completed Bellin College Application with non-refundable $50 application fee. 2. One official copy of all post high school (e.g., college/university) transcripts. Transcripts must be sent directly by the college/university to be considered official. 3. Goal Statement and Resume/Curriculum Vitae. The goal statement will be evaluated on the quality of its writing. 4. Two completed reference forms. 5. Copy of current licensure required prior to enrollment. If license will expire prior to enrollment you must provide an updated license. 6. TOEFL: if taken, Bellin College will require an official copy of the score. 7. Personal interview via phone or on campus. Health Requirement Students must provide evidence of meeting the health requirements prior to enrollment. Background Check Students must have a background check completed prior to enrollment. CPR Students must provide evidence of CPR certification prior to enrollment and annual renewal thereafter. Personal Interview A personal interview is required. When all application materials have been received (please refer to number 1 through 6 above) an interview will be scheduled. The appointment will be scheduled with the MSN Admissions Committee. Interviews are scheduled in person on week days between the hours of 7:30 a.m. and 5:30 p.m. and take approximately one hour. Applicant Goal Statement Guidelines Please write a two-to-three page, typed document that describes your: area of clinical interest reasons for desiring to become a Family Nurse Practitioner career goals, and career plans. Use professional writing with attention to content, grammar, syntax, spelling, and punctuation. The goal statement is evaluated as evidence of the applicant s ability to write at a level consistent with graduate education. Applicant Resume/Curriculum Vitae Guidelines The resume or curriculum vita is to include, but not be limited to, the following items: 1. Educational preparation 2. Employment as a registered nurse (employer, date, position/title) 3. Current licenses and certifications

3 4. Memberships in professional organizations (date, position held) 5. Scholarly endeavors a. Research activities (project, funding sources, date, your role) b. Presentations (title, date, organization, location) c. Publications (title, date, journal or book title, publisher) d. Honors awarded for scholarship and professional recognition (title, date, sponsor) e. Community service activities (date, organization, activity)

4 BELLIN COLLEGE 3201 Eaton Road Green Bay, WI NONDISCRIMINATORY POLICY STATEMENT It is the policy of Bellin College to be nondiscriminatory because of color, race, national origin, religion, age, sex, marital status or handicap in the admission of students. APPLICATION FOR ADMISSION MSN PROGRAM or toll free x6628 For questions, Website: OFFICE USE: TRACK OPTION: DATE APPLICATION RECEIVED: You are urged to give careful consideration to each question on this form. It is to your advantage to fill this out completely. Return the application promptly to the Admission s Office of Bellin College WITH $50 NONREFUNDABLE APPLICATION FEE. PRINT OR TYPE ALL INFORMATION BELOW: Last Name: First Name: Middle Name: Date of Birth (Example: 01/01/1999): Address: Social Security Number: - - Nick Name: Previous Last Name(s): Gender: Male Female RN Licensure: (please attach copy) Ethnic Heritage: Check one below. State(s) License Number Expiration date The following student data does not affect your admission status and is requested only to aid in the completion of federal, state, and college reports. 1. Ethnicity: Are you of Hispanic or Latino/a origin? Yes No 2. Race: Choose one or more from the list below: American Indian/Alaska Native Specify tribal affiliation Asian Laotian Cambodian Vietnamese Other Black/African American Native Hawaiian/other Pacific Islander White Are you a Veteran? Yes No If yes, select one: Chapter 30 Chapter 31 Chapter 33 Chapter 1606 Chapter 1607 Unknown Are you a dependent of a veteran? Yes No Are you a U.S. Citizen? Yes No (If No, you must complete the International/Non-U.S. Citizen application.) Did either parent attend or complete college? Yes No Have you applied to Bellin College in the past? Yes No PROGRAM TRACK See catalog for description. Please indicate which program track you are most interested in: Nurse Educator Family Nurse Practitioner ADDRESS INFORMATION Provide the address where you prefer to receive college mail: Primary Address: Number, Street and Apartment City State Zip Code County of Residency Telephone - - Cell Phone - - Check if Permanent Address is same as above primary address. If not, provide below: Work Phone - - Permanent Address: Number, Street and Apartment City State Zip Code County of Residency Telephone - - Cell Phone - - Work Phone - - Bellin College MSN Application (Printable) Rev. 9/2011 Page 1 of 2

5 EMERGENCY INFORMATION Person to be notified in case of emergency: Name: Address: Last Name First Name Relationship: Number and Street (if different than above) City State Zip Code Telephone - - Cell Phone - - Work Phone - - POST-SECONDARY EDUCATION List all educational institutions attended following high school AND any current college courses. IMPORTANT: Official transcripts MUST be mailed from institution directly to Bellin College to be accepted. Transcript Dates (mm/yyyy) Requested Name of Institution City and State Degree From To (Self-Check) REFERENCES: List two individuals who will be receiving the reference form. Two professional references (1 academic, if appropriate). It is the responsibility of the applicant to distribute their reference forms. 1. Name: Position or Title: 2. Name: Position or Title: CRIMINAL HISTORY: Do you have a conviction record or pending charges (excluding minor traffic violations)? Yes No If you checked yes to the previous question, please contact the Vice President of Student Services for further direction before applying to the College. Bellin College reserves the right to deny admission or to terminate enrollment of any student because of his or her criminal history. Prior to practicum placement, a criminal background check will be completed. This background check is completed to remain in compliance with the Wisconsin Caregiver Background Check and Investigation Legislation. If any of the information provided in this application changes during your enrollment at Bellin College you agree to supplement this application with additional information. It is understood and agreed that any misrepresentation, false statement or omissions by me in this application or during any interview conducted in connection with my application may result in denial of acceptance into Bellin College or termination of my status as a student of Bellin College without liability to the College. Applicant s Signature Print, complete, and sign application. Mail with application fee to: Date MSN Admissions BELLIN COLLEGE 3201 Eaton Road Green Bay, WI Bellin College MSN Application (Printable) Rev. 9/2011 Page 2 of 2

6 BELLIN COLLEGE Master of Science in Nursing Program FAMILY NURSE PRACTITIONER Reference Form Applicant: Reference: Please fill out page 1 and forward to your designated reference. Please fill out page 2 and return to: Bellin College MSN Admissions 3201 Eaton Road Green Bay WI The applicant named below is applying for admission to Bellin College Master of Science in Nursing program. Your assistance in completing the questions on page 2 will be very valuable to us in considering this candidate for admission. Applicant Name: I authorize to complete this reference form. WAIVER I understand that, under the provision of the Family Educational Rights and Privacy Act of 1974, I have the right to examine this recommendation unless such right is waived. (Please indicate below whether or not you wish to waive this right by checking the appropriate box and completing the signature and date). I expressly waive my right to examine or otherwise have access to this recommendation. I do not expressly waive my right to examine or otherwise have access to this recommendation. Signature: Date: NOTICE TO THE PERSON WRITING THIS RECOMMENDATION: Unless the above waiver is checked and signed, this recommendation may be examined by the applicant.

7 EVALUATION APPLICANT NAME 1. Please rate this applicant on each item as compared to other individuals of similar education and experience with whom you have been associated. Use the following scale, or feel free to attach a letter. 3. Outstanding 2. Above Average 1. Below Average X Insufficient knowledge to rate Ability in oral expression X Ability in written expression X Clinical competence X Dependability and Integrity X Intellectual capacity X Motivation X Organizational skills X Potential to succeed in graduate study X Responsiveness to constructive criticism X Skill in interpersonal interactions X 2. PLEASE DESCRIBE THE APPLICANT S STRENGTHS AND AREAS FOR IMPROVEMENT. 3. PLEASE DESCRIBE YOUR ASSESSMENT OF THE APPLICANT S ABILITIES AND POTENTIAL FOR SUCCESS IN A GRADUATE PROGRAM? PLEASE COMMENT ON CLINICAL JUDGMENT AND POTENTIAL FOR AUTONOMOUS PRACTICE. 4. PLEASE DESCRIBE YOUR ASSOCIATION WITH THE APPLICANT INCLUDING DATES. 5. WOULD YOU RECOMMEND THIS PERSON FOR GRADUATE STUDY? REFERENCE: Name (Print) Signature Title Institution Address Telephone address Date NEW FNP Pg. 2 of 2

8 BELLIN COLLEGE Master of Science in Nursing Program FAMILY NURSE PRACTITIONER Reference Form Applicant: Reference: Please fill out page 1 and forward to your designated reference. Please fill out page 2 and return to: Bellin College MSN Admissions 3201 Eaton Road Green Bay WI The applicant named below is applying for admission to Bellin College Master of Science in Nursing program. Your assistance in completing the questions on page 2 will be very valuable to us in considering this candidate for admission. Applicant Name: I authorize to complete this reference form. WAIVER I understand that, under the provision of the Family Educational Rights and Privacy Act of 1974, I have the right to examine this recommendation unless such right is waived. (Please indicate below whether or not you wish to waive this right by checking the appropriate box and completing the signature and date). I expressly waive my right to examine or otherwise have access to this recommendation. I do not expressly waive my right to examine or otherwise have access to this recommendation. Signature: Date: NOTICE TO THE PERSON WRITING THIS RECOMMENDATION: Unless the above waiver is checked and signed, this recommendation may be examined by the applicant.

9 EVALUATION APPLICANT NAME 1. Please rate this applicant on each item as compared to other individuals of similar education and experience with whom you have been associated. Use the following scale, or feel free to attach a letter. 3. Outstanding 2. Above Average 1. Below Average X Insufficient knowledge to rate Ability in oral expression X Ability in written expression X Clinical competence X Dependability and Integrity X Intellectual capacity X Motivation X Organizational skills X Potential to succeed in graduate study X Responsiveness to constructive criticism X Skill in interpersonal interactions X 2. PLEASE DESCRIBE THE APPLICANT S STRENGTHS AND AREAS FOR IMPROVEMENT. 3. PLEASE DESCRIBE YOUR ASSESSMENT OF THE APPLICANT S ABILITIES AND POTENTIAL FOR SUCCESS IN A GRADUATE PROGRAM? PLEASE COMMENT ON CLINICAL JUDGMENT AND POTENTIAL FOR AUTONOMOUS PRACTICE. 4. PLEASE DESCRIBE YOUR ASSOCIATION WITH THE APPLICANT INCLUDING DATES. 5. WOULD YOU RECOMMEND THIS PERSON FOR GRADUATE STUDY? REFERENCE: Name (Print) Signature Title Institution Address Telephone address Date NEW FNP Pg. 2 of 2

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