PLEASE READ ALL OF THE ABOVE INFORMATION

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1 INFORMATION FOR THE CLASS OF 2016 Huntsville Memorial Hospital's Joe G. Davis School of Vocational Nursing is approved by the Texas Board of Nursing and the Texas Education Agency The program is a twelve (12) month consecutive program. The program consists of classroom, laboratory, and clinical experiences. In addition to Huntsville Memorial Hospital, other health care facilities in the area are used for clinical rotations. A diploma is issued upon satisfactory completion of all program requirements. Graduates of the program are eligible to take the State Board Licensing Examination known as the NCLEX. More information concerning eligibility may be obtained at The graduate is not considered to be a Licensed Vocational Nurse (LVN) until successfully passing the State Board Licensing Examination. ALL STUDENTS MUST COMPLETE FBI FINGERPRINTING AND TEXAS BOARD OF NURSING BACKGROUNG CHECK CLEARANCE BEFORE ATTENDING SCHOOL * NO EXCEPTIONS* BEGINNING THE PROCESS Submit your fully completed/signed application with Official GED scores/high school/college transcripts/licenses to Joe G. Davis School by mail or in person. All applications must be in possession of the school no later than the last day of August, PRE-ENTRANCE EXAMINATION Test can be scheduled as soon as your fully completed/signed application and official transcripts/licenses are verified as received by the school. AT LEAST (10) DAYS BEFORE TESTING: Potential students must phone SHSU in advance to schedule time and pay a $50 nonrefundable deposit. They may pay this in person or via phone. Their appointment to test will not be set until payment is received. When they arrive for the test, they must pay the balance due of $ If they fail to arrive for the scheduled test, they will be required to pay an additional $ The total cost for the testing is $ This is an estimated cost only. Please call SHSU at to verify actual cost. After Submission: Test location Sam Houston State University testing center. Center is open Monday Friday testing times are 8am to 11am. If you choose to retake the test, the last test taken is the score that will be used by the school, but all scores must be submitted. All testers must bring a picture ID. All students must submit test scores to the school on the day you are tested. INTERVIEW REQUIREMENTS Official GED/high school transcript/ college transcripts/licensures. Good physical and mental health Picture ID (ex: Driver s License) Completed application and any additional requested paperwork at time of interview. Satisfactory score on the school s preentrance examination. At least four (4) personal references. No relatives or extended family members will be accepted. At least three (3) work references if you have ever been employed. (If you have less than 3, submit 2 additional personal references). Proof of starting the Hepatitis B Vaccine Series. A titer will be required for selected applicants prior to attending class. Proof of all vaccines (TB, MMR, TD, Flu, Chicken Pox and Hepatitis B series). TUITION AND FEES: The tuition is $ for the year and must be paid in full no later than (2) weeks before the first day of school. Estimated additional costs (Books, uniforms, etc.) could range up to $ depending on non-affiliated vendor cost. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. Mail completed applications to: Joe G. Davis School of Vocational Nursing P O Box 4001 Huntsville, Texas Telephone: Applications will be accepted for processing the month of May PLEASE READ ALL OF THE ABOVE INFORMATION Classroom facilities are located at: 521 I-45 South, Suite 8, Huntsville, TX. Application reviewed by the Advisory Committee

2 STUDENT APPLICATION FOR CLASS OF 2016 Joe G. Davis School of Vocational Nursing HUNTSVILLE MEMORIAL HOSPITAL P.O. Box 4001 Huntsville, Texas (936) SCHOOL USE ONLY Test: Test: Joe G. Davis School of Vocational Nursing is an equal opportunity institution and complies with all federal and Texas laws, regarding affirmative action requirements in all programs and policies. In compliance with Title VII of the Civil Rights Act of 1964, as amended by the Equal Opportunity Act of 1972, and Section 504 of the Rehabilitation Act of 1973, and the Older Americans Amendment of 1975, this institution does not discriminate on the basis of age, race, color, religion, sex, national origin, or disability in administration of its education policies, admissions policies, scholarship programs, and other school administered programs PLEASE PRINT ALL INFORMATION INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED Last Name First Name Middle Name Maiden Name Street Address (If different from ) City State Zip Code Home Phone Cell Phone Work Phone Address Social Security Number Date of Birth Texas Drivers License/ID Number Alternate Address PERSONAL INFORMATION Do you have any business, social/family obligations or medical conditions that would prevent you from attending school consistently if you are accepted? Yes No If Yes, please explain below. FOR SCHOOL USE ONLY Date Received: Are you either a U.S. Citizen or an alien who has the legal right to attend school in the U.S.A.? Yes No If no, are you considered a permanent resident? Yes No Card # Are you a former student of the Joe G. Davis School of Vocational Nursing? Yes No If "Yes", year enrolled Have you previously applied for enrollment in this school? Yes No Year:

3 EDUCATION AND TRAINING The applicant is to furnish the School of Vocational Nursing original transcripts from each of the listed educational facilities. If applicable, a photocopy of the GED report showing test scores must be furnished to the School. LAST YEAR NAME OF INSTITUTION COURSE OF STUDY COMPLETED DID YOU GRADUATE? MONTH/YEAR GRADUATED (High School City/State) YES NO GED (State Obtained) (College) (Vocational/Tech School) YES NO YES NO Please answer the following questions: 1) No Yes For any criminal offense, including those pending appeal, have you: A) been convicted of 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 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.) 2) No Yes Do you have any criminal charges pending, including unresolved arrests? 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 or certificate 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 disorder, bipolar disorder, paranoid personality disorder, antisocial personality disorder, or borderline personality disorder? Yes No If YES, indicate the condition: schizophrenia and/or psychotic disorders, bipolar disorder, paranoid personality disorder, antisocial personality disorder, borderline personality disorder All students must have full clearance with the Texas Board of Nursing prior to attending nursing school. The questions above may determine your eligibility to attend nursing school and to become licensed. For more information on eligibility please contact the Texas Board of Nursing at (512)

4 EMPLOYMENT HISTORY Beginning with most recent employment, please provide COMPLETE CURRENT MAILING ADDRESSES FOR EACH PLACE OF EMPLOYMENT LISTED INCLUDING ZIP CODES and CORRECT employment dates. Do not list self-employment or those that no longer are in business. List only employments that can be verified. Incorrect information/omitted information may delay or cause your application not to be processed for final review. Incomplete information may result in applicant not being able to register to test or attend school. PLEASE NOTE: IF LESS THAN THREE (3) WORK REFERENCES PLEASE PROVIDE TWO (2) ADDITIONAL PERSONAL REFERENCES PLEASE PRINT LEGIBLY COMPLETE MAILING ADDRESSES on your work and personal references are required. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.

5 Personal references - do not list relatives or employers. Use counselors, teachers, coworkers, church members, etc. Do Not list as personal references the same persons listed as supervisors in your employment history. Incorrect/omitted information may delay or cause your application not to be processed for final review. PLEASE PRINT LEGIBLY PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS APPLICATION FORM: I certify that all statements made on this application are true and correct. I authorize former employers to release any information they may have regarding employment. I release from liability any person giving or receiving information pertinent to the investigation or verification of data provided in this application. If anything contained in this application and/or resumé is found to be untrue, I understand that I will be subject to dismissal or rejection. I understand that I will be subject to a personal interview and a photograph will be taken of me prior to the interview and attached to my application. I understand if I am accepted into the school, I will be required to have a physical examination and based on the information received from this exam, more information may be requested. I further understand that I will be required to be immunized for various diseases as recommended by the Texas Department of Health. I consent to random drug testing by urinalysis or blood tests to determine substance use and/or abuse at any time during the application process and/or school year. I understand a criminal background/history check will be made by Huntsville Memorial Hospital in the application process and the Texas Board of Nursing in order to attend school. The BON background check may result in my failure to be eligible to attend the Joe G. Davis Vocational School of Nursing or for taking the state board exam and licensure as a Vocational Nurse in the State of Texas. Printed Name Signature Date OFFICIAL HIGH SCHOOL/GED/COLLEGE TRANSCRIPTS MUST BE SUBMITTED WITH THIS FULLY COMPLETED AND SIGNED APPLICATION.

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