STUDENTS ARE RESPONSIBLE FOR THEIR OWN HEALTH INSURANCE

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1 Page 1 of 4 Date: Part A RN Student Reapplication to Program NORTH ARKANSAS COLLEGE Department of Nursing & Allied Health Programs Application for Admission LPN-RN-Associate Degree (AAS) Program Demographic Data First Application Transfer from: (Name of School) Second Application Northark Student ID: Last Name: First: Middle: Maiden: Third Application Social Security Number: Other Allied Health Programs Applying for: Address: City: State: Zip: RT MLT ST Paramedic Boone County Resident Yes No US Citizenship Yes Gender: M Part B F No Home Phone: Cell Phone: Northark address: Work Phone: Message Phone: Personal address: Personal Health Information Date of Birth: Age: Person to notify in case of emergency: Relationship: Home Phone: Work Phone: Physician Name: Address: City, State Zip: Physicians Phone: STUDENTS ARE RESPONSIBLE FOR THEIR OWN HEALTH INSURANCE Have you ever had: Do you presently have: Yes No Yes No Orthopedic Problems Yes No Yes No Chemical Dependency Yes No Yes No Chronic Communicable Disease Yes No Yes No Psychiatric Problems Yes No Yes No Dental Problems Yes No Yes No Neurological Problems Yes No Yes No Other significant health problems Any physical defects or limitations? Yes No If Yes, then please describe any health problems on the back of this sheet. Include duration, treatments and resolution of the problem(s). Medical clearance is required on any health problem that could interfere with the ability of the student to meet the performance criteria of the program, endanger the safety of a client and/or jeopardize the health of the student if he/she attempts to meet the performance criteria. THIS FORM IS NOT COMPLETE WITHOUT ATTACHMENTS, THE STUDENT S SIGNATURE, AND A PHYSICIAN S SIGNATURE IF MEDICAL CLEARANCE IS NEEDED.

2 Page 2 of 4 There is no health insurance coverage provided for students by either the clinical facilities or North Arkansas College. Students are expected to be personally responsible for treatment needed due to accidental injury or health risks. Students are strongly advised to purchase personal health insurance and are encouraged to take the hepatitis B vaccine. I understand that there are performance criteria (critical requirements) established for skills taught and that all students are expected to master these skills, e.g. psychomotor skills include: cardiopulmonary resuscitation for health care providers and the transfer of clients, which requires lifting and moving, according to the performance criteria. Student Signature Date TO BE COMPLETED ONLY IF MEDICAL CLEARANCE IS NEEDED: I have examined and give him/her medical clearance to enroll in the nursing program at. Signature of Physician Date Description of Health Problems (if applicable):

3 Part C Application Submitted Yes No Required Records Yes Transcripts Submitted Include a copy of current professional health related license(s). State of Licensure(s): CNA LPN No Paramedic Other If you have not already done so, please request that all transcripts, high school, GED, and ACT scores, college or colleges, LPN School or other, be sent directly to the ADMISSIONS OFFICE NORTH ARKANSAS COLLEGE Harrison, Arkansas from the respective institutions, bearing the imprint of the institution's seal (official transcript). Include official High School transcript or documentation of GED. All transcripts must be received before application deadline to be considered. Page 3 of 4 If Licensed Practical or Vocational Nurse LPN or LVN Name of School Address Date of Attendance Date of Graduation List college(s) attended. 1. Name of College Complete Address (if known) Dates of Attendance Date of Graduation Degree/Credit Earned 2. Name of College Complete Address (if known) Dates of Attendance Date of Graduation Degree/Credit Earned 3. Name of College Complete Address (if known) Dates of Attendance Date of Graduation Degree/Credit Earned Note: If more than 3 colleges use separate sheet with above information. Work Experience LIST CURRENT EXPERIENCE FIRST (include nursing, or related work experience, business or other) 1. Name of Employer Address Position Dates of Employment Reason for Leaving 2. Name of Employer Address Position Dates of Employment Reason for Leaving 3. Name of Employer Address Position Dates of Employment Reason for Leaving 4. Name of Employer Address Position Dates of Employment Reason for Leaving

4 Please submit the following with this application to: Page 4 of 4 RN Program Director Harrison, AR Copy of current unencumbered LPN license number for verification. Evidence of at least 3 months or 120 hours of work experience within the last year and job description as a LPN from the Director of Nursing Services (or equivalent) on letterhead stationary from the facility. Work Verification Form-The work requirement may be waived if the applicant has graduated from a PN program in the previous year before application. The applicant must obtain a letter of recommendation from a PN instructor or the PN Director. Attach MMR s if you have not already submitted to the College. Those born after 1/1/57 must furnish proof of measles and rubella vaccines that have been received after the first birthday and after 1/1/68. Two MMR s or a positive Rubella titer for antibodies is a standard requirement. If you have a current copy of the following please submit with your application: Tuberculin skin test (TB) 2 within the last year (two-step or annual). CPR certification (American Heart Association-Healthcare Provider) Current and up to date immunizations: Tdap within the last 10 years Varicella Hepatitis B 10 Panel UA Drug Screen (details will be given at orientation if accepted into program) These documents will be required upon acceptance into the program. Falsification of any information in this application may result in dismissal from the program. I have have not pled guilty or nolo contendore or been convicted of a crime or offense listed in Act 1208 of 1999 in the state of Arkansas. I have do not have any criminal convictions in expunged or sealed records (these records are discoverable by RN Licensing Boards). If yes, explain: See statement below for signature: My signature indicates that I have read Act 1208 of 1999 and I understand if I graduate from the RN program at North Arkansas College I may not be able to sit for the licensure exam (NCLEX-RN) if I have pleaded guilty or nolo contendore to, or been found guilty of any of the offenses listed in the Act. Signature Date Revised 7/2015

5 Students applying to the LPN-RN Bridge program will receive 10 points for work experience as an LPN greater than 3 months in length or 120 hours. Documentation of work history, which must include job description, must be provided on the form from Department of Nursing. The Director of Nursing or the RN manager should fill out the form and sign the form verifying authenticity. The form should be mailed directly to the RN nursing department in a sealed envelope to the following address: Department of Nursing ATTN: Kim Tinsley, MSN, RN, CNE LPN-RN Director Harrison, AR 72601

6 Department of Nursing Verification of Work History and Recommendation LPN-RN Applicants LPN-RN Applicants Name Date Briefly describe the job duties of the LPN who is applying for a position in the LPN-RN Bridge Program: Hire Date OR PN program attendance dates Is the applicant currently employed by this facility? YES NO (if no supply end date) Please describe the LPN-RN applicant s work ethic: Would you recommend the applicant to be considered for the LPN-RN Bridge Program? YES NO (if no, then please provide reason in space below) Signature Title Please mail this form directly to: Department of Nursing ATTN: Kim Tinsley, MSN, RN, CNE LPN-RN Director 1515 Pioneer Dr. Harrison, AR 72601

7 Dear LPN-RN Applicant: Please use the provided transcript request form in order to have official transcripts sent to the Admission s Office at Northark. Only official transcripts will be considered, and the deadline for receiving information is September 1. Good Luck on your application process, The Nursing Faculty of Northark

8 Date Please send an official transcript of my credits to: Admission s Office Harrison AR If any charge, please bill me at the address below. Last Name First Middle Maiden Mailing Address City State Zip Code Date of Birth Dates of Attendance Social Security No. Signature PLEASE ATTACH THIS FORM TO TRANSCRIPT Date Please send an official transcript of my credits to: Admission s Office Harrison, AR If any charge, please bill me at the address below. Last Name First Middle Maiden Mailing Address City State Zip Code Date of Birth Dates of Attendance Social Security No. Signature PLEASE ATTACH THIS FORM TO TRANSCRIPT

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