Application for. Application for Fall 2016 ADN-BSN PROGRAM.

Transcription

1 Last Name: First Name: Application for Application for Fall 2016 ADN-BSN PROGRAM California State University, Monterey Bay Department of Extended Education

2 CSU Monterey Bay maintains an environment free of unlawful discrimination in any of the University's programs or activities of education and employment. Accordingly, discrimination on the basis of race, color, religion, national origin, sex (including sexual harassment and sexual assault), sexual orientation, marital status, pregnancy, age, disability, medical condition and covered veteran status is prohibited. This policy is conducted in accordance with Title VI and Title VII of the Civil Rights Act of 1964, as amended, the Age Discrimination in Employment Act of 1967, Title IX of the Educational Amendments of 1972, Sections 503, 504 and 508 of the Rehabilitation Act of 1973, the Vietnam Era Veteran's Readjustment Assistance Act of 1974, the Americans with Disabilities Act (ADA) of 1990, the California Fair Employment and Housing Act, California State University (CSU) Executive Orders 883 and 927, and appropriate Collective Bargaining Agreements (CBA). Department of Nursing, CSUMB ADN-BSN Application Interested applicants must apply to both CSU Monterey Bay (on-line) AND the Nursing Program (in hard copy). Thank you for your interest in the CSUMB Nursing Program. Please follow instructions and submit completed application forms along with your goal statement before April 1, CSU Monterey Bay application instructions: Submit online CSUMB application via CSU Mentor ( and submit $55 application fee online. Send official transcripts of ALL previous undergraduate work. Transcripts must be in English or translated into English. Mailing address: CSUMB Office of Admissions, Student Service Bldg. 47, 100 Campus Center, Seaside, CA Official transcripts may be submitted electronically to the CSUMB Office of Admissions. Send a copy of current RN license in California (If you are a current ADN student, please inform us of your application process or the NCLEX test date). If applicable, refer to Foreign Credential Evaluation and Equivalence at for college/university academic work awarded outside of the United States. Applying for FULL time enrolment Applying for PART time enrolment Student Disability Resources Applicants that require disability-related accommodations at CSUMB are to contact CSUMB Student Disability Resources at student_disability_resources@csumb.edu ( ), (831) (phone), (831) (fax/tty), Department of Nursing Program Application Application Period : October 1, 2015 April 1, 2016 Page 2 of 11 (Rev.09/15)

3 Nursing Program Application Information Interested applicants must apply to both CSU Monterey Bay (on-line) and the Nursing program (in hard copy). CSUMB ADN-BSN Nursing Program applications will be accepted October 1, 2015 April 1, Applicant To-Dos: Complete all areas of the Nursing Program Application. Print and submit final documents to the Department of Nursing located in Green Hall, Bldg. 58. Hand written information must be legible. Only legible and complete applications will be reviewed. All primary communication will be via , so please submit an that you regularly check. Please check the Nursing program website (nursing.csumb.edu) and your regularly for updates. Sign all pages that provide a signature line Incomplete applications will not be returned or reviewed. Mailing address: CSUMB-Extended Education Nursing Program 100 Campus Center Green Hall, Bldg. 58 Seaside, CA All Nursing Application documents are to be mailed certified US postal mail and must be post marked no later than April 1, 2016, or delivered in person to the Nursing Program office, Green Hall, Building 58, by April 1, The Nursing Program Application consists of the following documents: 1. Student information 2. Work-related nursing experience and language proficiencies 3. Nursing Program Admission Worksheet 4. Background information form - This advisement is intended to inform applicants of possible program and career limitations for those with criminal history. 5. Student verification - This form is to be completed by the director of nursing at the Community College for students who expect to graduate from an ADN program in May or June Guidelines for Goal Statement - This should be a concise, well-written essay about your goals in pursuing a BSN. 7. Certification Final signature page DEPARTMENT OF NURSING AND-BSN PROGRAM APPLICATION Department of Nursing Program Application Application Period : October 1, 2015 April 1, 2016 Page 3 of 11 (Rev.09/15)

4 Student Information (please print clearly) Application Period October 1, 2015 April 1, 2016 Legal Name: First Name (Given Name) Middle Name Legal Family Name (Surname) Preferred Name (Nickname): Gender: Male Female CA RN License Number NCLEX Test Date Citizenship: Are you a U.S. Citizen? Yes No Other (please specify): Current mailing address (: ) Street address or PO Box City state/province zip/postal code county/country Permanent mailing address Same as current Street address or P.O. Box City state/province zip/postal code county/country Permanent Phone: Cell Phone: Address: Please use an address that you regularly check Military: Have you ever been on active duty in the U.S. military service? Yes No If Yes, please indicate whether you are currently an active duty member or a veteran of the U.S. armed forces. _ Active Duty Member _ Veteran If you select Yes, submit a copy of your DD214 or DD295 with this application form for an evaluation of credit. High School Graduated: Name of High School City, State County/Country College/University attended (most recent first): a. Name of University City, State County/Country b. Name of University City, State County/Country c. Name of University City, State County/Country d. Name of University City, State County/Country Department of Nursing Program Application Application Period : October 1, 2015 April 1, 2016 Page 4 of 11 (Rev.09/15)

5 Work-Related Nursing Experience List your recent employment experiences as a Registered Nurse or employment / volunteer experience in health care or related area. List your most recent experience first. #1 Employed as: Volunteer Internship Employee From (mm/yyyy) - Hours/week: Briefly describe your duties: Agency Name: Position: Street address or P.O. Box City state/province zip/postal code county/country Employment: Nursing or Non-Nursing Name of Supervisor: Title: Phone number: #2 Employed as: Volunteer Internship Employee From (mm/yyyy) - Hours/week: Briefly describe your duties: Agency Name: Position: Street address or P.O. Box City state/province zip/postal code county/country Employment: Nursing or Non-Nursing Name of Supervisor: Title: Phone number: References: Please provide 2 references. It can be either your employer or from a professor. Please send and include the sealed envelopes with this application. Language Proficiencies What is the primary language spoken at home: What is your native language? English Chinese French German Japanese Spanish Other: Indicate your proficiency in any spoken language(s) other than English and/or American Sign Language: Language Native Speaker? Able to Translate? Proficiency (write in: low/med/high) How did you develop this proficiency? Please explain: Yes No Yes No Speaking Reading Writing Yes No Yes No Speaking Reading Writing Yes No Yes No Speaking Reading Writing Department of Nursing Program Application Application Period : October 1, 2015 April 1, 2016 Page 5 of 11 (Rev.09/15)

6 Department of Nursing Program Admission Worksheet The BSN curriculum is a 50-unit undergraduate program. In order to prepare for Baccalaureate Nursing Education, students must have a knowledge base that includes the biological sciences, humanities, and an understanding of society, social problems, and human behavior. The following CSUMB admission requirements must be fulfilled before the start of the Fall Computer experience: Students are required to have internet and access. Proficiency with word processing (Microsoft Word ), Presentation software (Microsoft PowerPoint ) or Prezi is necessary throughout the CSUMB Nursing Program. Transfer Worksheet Please complete using your transcript Transfer requirements. See assist.org for assistance in identifying General Education transfer courses Find your community college(s) under GE Breadth and complete the table below General Education Course / Category College or University Course # & Title Units Semester & Year Grade Area A: English Language (grade C or higher): A1 Oral Communication* A2 Written Communication* A3 Critical Thinking* Area B: Scientific Inquiry & Quantitative Reasoning (Statistics preferred)* B1 Physical Science Chemistry ALL CSU nursing programs require a college level chemistry course. B2 Life Science B3 Laboratory Activity B4 Mathematics (Statistics) including Basic Statistics, Elementary Statistics, Introduction to Statistics, Quantitative Literacy or Social Statistics. Be advised that the statistics course is strongly recommended to have been completed within the last five years. Department of Nursing Program Application Application Period : October 1, 2015 April 1, 2016 Page 6 of 11 (Rev.09/15)

7 Area C: Arts & Humanities C1 Arts C2 Humanities C3 World Language and Cultures Area D: Social Sciences D1 Social Science D2 US Histories and Democratic Participation Two courses are required (see US1, Same as US 2/3 below) American Institutions (CSU System requirement) US1 US History US2/3 US/ California Constitution Area E: Lifelong Understanding and Self Development *Areas A1, A2, A3 and B4 are known as the Golden Four and are required for CSUMB matriculation Department of Nursing Program Application Application Period : October 1, 2015 April 1, 2016 Page 7 of 11 (Rev.09/15)

8 Background Information form Step 1 Step 2 Completion of this form is required for ALL Department of Nursing program applicants. Submit the completed document with your CSUMB Nursing Application. Students with a history of arrests or convictions need to know that this may prohibit placement in certain agencies and may result in your inability to remain or continue in the Nursing Program. Additional Information Required (After Acceptance to the CSUMB Department of Nursing Program) CSUMB Department of Nursing requires criminal background check clearance upon admission. Hospitals and community health care agencies require students, volunteers, and employees to undergo background checks as a condition of employment and clinical placement. Prior to undertaking any CSUMB community activities, you will be required to submit a background check. Official background checks will include state and federal criminal record checks that include checks of central child abuse registries, and checks of sex offender registries. While criminal history information is evaluated on a case-by-case basis, applicants should be aware of possible limitations on clinical placement opportunities. Review Process If an applicant is qualified to be accepted to the program, his/her prior criminal history may result in a further review. If you would like to discuss your circumstances or questions, please schedule an appointment with the Director of Nursing. Upon admission to CSUMB Department of Nursing, students are also required to submit documentation of immunizations, TB clearance, current RN license, CPR (AHA Healthcare Provider) certification, professional liability insurance, a drug screening (urine) test and a recent health physical examination to CertifiedBackground.com (approximately $130 one-time fee) I certify that I have read and understand the above information. Applicant Signature: Date: Clearly Print Name: Department of Nursing Program Application Application Period : October 1, 2015 April 1, 2016 Page 8 of 11 (Rev.09/15)

9 Student Verification form If you are a current ADN student, what is your expected graduation date? Applicant Signature: Date: Please obtain the signature of ADN program director or their designee verifying the expected date of graduation: Expected Date of Graduation Director or Designee (Adviser or coordinator) Department of Nursing Program Application Application Period : October 1, 2015 April 1, 2016 Page 9 of 11 (Rev.09/15)

10 Guidelines for Goal Statement The Goal Statement helps the admissions committee understand your career objectives and how the CSUMB BSN program will assist with accomplishment of your goals. Please follow the format requirements. Remember to include your name on all pages of the goal statement. Applicants are to submit the goal statement in the following format: Applicant name and contact information is required (Please use a header) Type document in 11 or 12--point font Use 1-inch margins (top, bottom, left & right) 2 pages Maximum, double-spaced Number pages consecutively Use headings or numbered responses to the questions below Sign and date completed statement CSUMB Mission Statement: To build a multicultural learning community founded on academic excellence from which all partners in the educational process emerge prepared to contribute productively, responsibly, and ethically to California and the global community. Please provide a personal goal statement that addresses the following (in less than 3 pages): 1. Discuss your reasons for pursuing a Baccalaureate degree in nursing. Describe how CSUMB Mission Statement relates to your career goals ( 2. Describe how you as a BSN graduate will contribute to the Nursing profession. 3. What do you consider to be your personal strengths (i.e. maturity, bilingual capability, leadership potential, etc.) that will help you reach your educational goals? Completed Applications will be evaluated based on the following criteria: 1. Admission to CSUMB 2. Transcripts: Graduate (or soon to graduate) from ADN program, prior BA / BS degree. Prior coursework GPA: GE Credit completion (Areas A-E) completed Includes completion of Statistics course and Chemistry (required by all CSU Nursing Program) 4. Goal Statement -- Demonstrates understanding of BSN role and career goals consistent with BSN completion 5. Qualified applicants may be invited for on campus interviews Department of Nursing Program Application Application Period : October 1, 2015 April 1, 2016 Page 10 of 11 (Rev.09/15)

11 Please check all boxes below and include with your application documents. Student Information with address Work-related nursing experience & language proficiencies Nursing Admission Worksheet form Background Information form Goal Statement Certification Final signature page Letters of References Certification I certify that I have read all of the instructions. I have answered all of the questions completely and truthfully. I understand that misrepresentation of any portion of this application, including supporting credentials and documents, may be cause for canceling my admission or financial award. I also understand that all credentials and documents that I submit become the property of the California State University, Monterey Bay. Applicant Signature: Date: Clearly Print Name: address: Phone: Optional Ethnic Survey: (This information is useful to us for statistical purposes and is not required.) American Indian/Alaskan Native Chinese/Chinese American Pacific Islander (Tribal affiliation) East Indian/Pakistani Other Asian Black/African American Japanese/Japanese American Non Hispanic-White/Caucasian Latino/Other Spanish American Korean/Korean American Other (please specify) Pilipino/Filipino Vietnamese/Vietnamese American Decline to state Department of Nursing Program Application Application Period : October 1, 2015 April 1, 2016 Page 11 of 11 (Rev.09/15)