POPLAR BLUFF TECHNICAL CAREER CENTER PRACTICAL NURSE PROGRAM APPLICATION PACKET CLASS #

Transcription

1 POPLAR BLUFF TECHNICAL CAREER CENTER PRACTICAL NURSE PROGRAM APPLICATION PACKET CLASS # Full Approval Status by the Missouri State Board of Nursing Approved by the Missouri State Department of Education Nationally Accredited by North Central Association

2 Table of Contents Page General Information 1 Application Process (includes Items # 1-7) 1 Selection 3 Informational Session 3 Financial Aid 3 Advanced Placement 3 Admission 3 English as Second Language 3 Tuition 4 Estimated Program Cost 4 Nurse Practice Act Licensure Information 4 NCLEX Eligibility & Requirements 5 Refunds of Tuition and Fees 6 Required Minimal Functional Abilities 6 Admission Requirements/Criteria 8 Curriculum Sequence 9 Request for Accommodations 11 Admission Rating System 12 Confidential Release Waiver, Agreement & 13 Criminal Background Check Authorization Application 14

3 TO: FROM: Applicants of the Poplar Bluff R-1 Practical Nursing Program Jolon Vaughn, MSN, RN-Coordinator of the Practical Nurse Program I am very pleased with your interest in the Poplar Bluff R-1 Practical Nurse Program. This application packet contains forms and information that you will need to apply for our next class which begins July It is important to read the entire packet thoroughly. This information has been provided for the purpose of completing the application process correctly and expediently. When printing this document off of the computer, please print it as a one-sided document. Printing this packet out as a two-sided document (or front & back) may cause it to print out incorrectly. The Application Process Consists of the Following Components and Criteria: ***Deadline for all items listed below is March 1st, 2014, NOON.*** 1. Application Form: Please complete the form as instructed (located on page 14). 2. Application Processing/Testing Fee: $50.00 non-refundable fee You may make money orders payable to: Poplar Bluff R-1 Schools In order to ensure application processing, please pay by cash or money order in the main office of the nursing school at 3203 Oak Grove Rd., Poplar Bluff, MO (Do not mail cash.) 3. Official High School Transcript - A copy of an official transcript from the high school from which you graduated is required. This may be obtained by requesting your school to send the transcript to our school. The transcript must have the school seal and/or signature of a school official. An official transcript may be hand delivered by you only if it is in its original institutional envelope and the seal has NOT been broken. Please have the school send the official transcript(s) to: Poplar Bluff TCC Practical Nurse Program 3203 Oak Grove Rd., Poplar Bluff, MO OR GED A copy of the GED scores and certificate must be obtained or an online transcript. You may find information on obtaining your online transcript by going online to: College Transcripts- A copy of a transcript from a college may be an unofficial transcript and may be hand-carried by the student to the school. 4. Criminal Background Check (Caregiver Background Screening): A. You must sign the Criminal Background Check Authorization located on page 13 in this packet. B. Must provide copy of marriage license or a divorce decree; drivers license; birth certificate; social security card; immunizations; and proof of address (utility bill) 5. Personal/Professional Recommendation: A. Please list the complete names and current addresses of three (3) individuals in the appropriate spaces on the application form. The names you put on the application must be who you give recommendation forms to. B. If at all possible include past or present employers, supervisors, co-workers or someone who has worked with you closely in the past two to three (2-3) years. This could include volunteer work, service projects, Parent Teacher Organization, Boy/Girl Scouts, Counselor, etc.

4 C. DO NOT list relatives, family physicians (unless work related). D. A recommendation form will be provided for the names you have listed in the application. The person doing the recommendation will be asked to return the form directly to the school. All three (3) references must be returned by February 27, 2014, by 12:00 Noon. The mailing address for the recommendations to be returned is: Poplar Bluff TCC, Practical Nurse Program 3203 Oak Grove Rd. Poplar Bluff, MO E. Please complete the enclosed confidential release waiver and return with your application. F. Please read the form and familiarize yourself with the aspects of your character the individual will be remarking on. This is an important component of the selection process. 6. Pre-Entrance Testing: A: The TEAS (Test of Essential Academic Skills), version V, is scheduled and administered at the Poplar Bluff TCC, Practical Nurse Program, 3203 Oak Grove Rd., Poplar Bluff, MO after the application has been completed and the application testing/fee has been paid. A written notice will be mailed to you on or before March 3, 2014, indicating the date and time of your test. A limited number of applicants will be scheduled for each test date. B: Scheduling/Rescheduling - You will be allowed to test once (1 time) during the application process. The dates listed below have been scheduled for pre-entrance testing. You may indicate two preferences for the scheduled test dates. However, priority will be given to the applicant who submits all required information first. It is also your responsibility to reschedule your test date if you are unable to make the date you selected or were assigned The test dates are as follows: March 8, 2014 Saturday 8am 12 noon March 11, 2014 Tuesday 1pm- 4pm 4:30pm to 8:30pm March 12, 2014 Wednesday 8 am 12 noon 1pm 4 pm The TEAS (Test of Essential Academic Skills) will consist of several sections including Reading, Mathematics, Science and English & Language Usage. This will be a timed test. You may not bring a calculator for the Math section. The TEAS Online Practice Assessment and the TEAS Study Manual, version V, may be purchased from ATI by going to or calling Selection - Applications will be reviewed and selection by the Admission Committee will primarily be based on the TEAS score results with strong consideration given to references, and transcripts. 8. Informational Session - In order for you to qualify for the informational meeting session with the nurse director or designated individual, you must first meet the testing criteria as outlined above. (Refer to Pre-Entrance Testing) Once the test results are received in our office and the Admissions Committee has had the opportunity to meet, you will be notified in writing or by phone of the interview dates and times. Once interviews are completed, you will receive a letter in the mail of your admission status. Please review the admission scoring sheet on page 12 before your interview. Informational Meeting session date will be included in your acceptance letter. Attendance of accepted individuals is required. If you are an alternate and wish to keep your place on the alternate list, your attendance at the Informational Meeting is required. Please notify the nursing office as soon as possible if there is an extenuating reason that would prevent you from attending.

5 During the session, information about the program will be given and test results discussed. An explanation of the admission rating system utilized by the selection committee will be provided. At this time, you have the opportunity to ask questions about the program, application process, admission rating system, etc. Important program policies will also be reviewed with you. You will schedule an appointment with the Financial Aid Advisor during this meeting. 9. Financial Aid - For information regarding financial aid, please speak with Gina Duckett, Financial Aid Secretary, in the Financial Aid Office at Poplar Bluff Technical Career Center, 3203 Oak Grove Rd., Poplar Bluff, MO or you may contact her by phone at (573) You will need to complete the FAFSA online prior to April 1, in order to have documentation in place before classes begin. That web address is The school code for FAFSA is See PBTCC Postsecondary Catalog Page 11 for Financial Responsibilities. 10. Advanced Placement Poplar Bluff R-1, Practical Nurse Program does not allow advanced placement of students. This is a requirement set forth by the Missouri State Board of Nursing regarding schools of practical nursing. All students, regardless of academic history, are required to attend the nursing program in its entirety. 11. Admission - No student will be admitted after five (5) days have passed since the established beginning date of classes for the academic year. 12. English as Second Language English as Second Language students are required to meet the same criteria as any other student. 13. Tuition will be In-District $ ; Out-of-District & $9,961.00; plus program fees of $2,970. This amount may be subject to change. The tuition includes fees for textbooks, uniforms, state board testing, lab supplies, professional liability insurance, name badge, stethoscope, standardized testing for NCLEX- PN readiness, and graduation pin. 3

6 ESTIMATED COSTS PRACTICAL NURSING PROGRAM Tuition... In- District 9, Out-of-District 9, Program Fees 2, Estimated Total In-District $12, Estimated Total Out-Of-District $12, *Tuition subject to change at any time upon approval/recommendation of the Poplar Bluff R-1 School Board.* 15. Nurse Practice Act Denial, revocation, or suspension of license, grounds for, civil immunity for providing information. 1. The board may refuse to issue any certificate of registration or authority, permit or license required pursuant to sections to for one or any combination of causes stated in subsection 2 of this section. The board shall notify the applicant in writing of the reasons for the refusal and shall advise the applicant of his or her right to file a complaint with the administrative hearing commission as provided by chapter 621, RSMo. 2. The board may cause a complaint to be filed with the administrative hearing commission as provided by chapter 621, RSMo, against any holder of any certificate of registration or authority, permit or license required by sections to or any person who has failed to renew or has surrendered his or her certificate of registration or authority, permit or license for any one or any combination of the following causes: (1) Use or unlawful possession of any controlled substance, as defined in chapter 195, RSMo, or alcoholic beverage to an extent that such use impairs a person's ability to perform the work of any profession licensed or regulated by sections to ; (2) The person has been finally adjudicated and found guilty, or entered a plea of guilty or nolo contendere, in a criminal prosecution pursuant to the laws of any state or of the United States, for any offense reasonably related to the qualifications, functions or duties of any profession licensed or regulated pursuant to sections to , for any offense an essential element of which is fraud, dishonesty or an act of violence, or for any offense involving moral turpitude, whether or not sentence is imposed; (3) Use of fraud, deception, misrepresentation or bribery in securing any certificate of registration or authority, permit or license issued pursuant to sections to or in obtaining permission to take any examination given or required pursuant to sections to ; (4) Obtaining or attempting to obtain any fee, charge, tuition or other compensation by fraud, deception or misrepresentation; (5) Incompetency, misconduct, gross negligence, fraud, misrepresentation or dishonesty in the performance of the functions or duties of any profession licensed or regulated by sections to ; (6) Violation of, or assisting or enabling any person to violate, any provision of sections to , or of any lawful rule or regulation adopted pursuant to sections to ; (7) Impersonation of any person holding a certificate of registration or authority, permit or license or allowing any person to use his or her certificate of registration or authority, permit, license or diploma from any school; (8) Disciplinary action against the holder of a license or other right to practice any profession regulated by sections to granted by another state, territory, federal agency or country upon grounds for which revocation or suspension is authorized in this state; (9) A person is finally adjudged insane or incompetent by a court of competent jurisdiction; 4

7 (10) Assisting or enabling any person to practice or offer to practice any profession licensed or regulated by sections to who is not registered and currently eligible to practice pursuant to sections to ; (11) Issuance of a certificate of registration or authority, permit or license based upon a material mistake of fact; (12) Violation of any professional trust or confidence; (13) Use of any advertisement or solicitation which is false, misleading or deceptive to the general public or persons to whom the advertisement or solicitation is primarily directed; (14) Violation of the drug laws or rules and regulations of this state, any other state or the federal government; (15) Placement on an employee disqualification list or other related restriction or finding pertaining to employment within a health-related profession issued by any state or federal government or agency following final disposition by such state or federal government or agency. 3. After the filing of such complaint, the proceedings shall be conducted in accordance with the provisions of chapter 621, RSMo. Upon a finding by the administrative hearing commission that the grounds, provided in subsection 2 of this section, for disciplinary action are met, the board may, singly or in combination, censure or place the person named in the complaint on probation on such terms and conditions as the board deems appropriate for a period not to exceed five years, or may suspend, for a period not to exceed three years, or revoke the license, certificate, or permit. 4. An individual whose license has been revoked shall wait one year from the date of revocation to apply for relicensure. Relicensure shall be at the discretion of the board after compliance with all the requirements of sections to relative to the licensing of an applicant for the first time. 5. The board may notify the proper licensing authority of any other state concerning the final disciplinary action determined by the board on a license in which the person whose license was suspended or revoked was also licensed of the suspension or revocation. 6. Any person, organization, association or corporation who reports or provides information to the board of nursing pursuant to the provisions of sections to * and who does so in good faith shall not be subject to an action for civil damages as a result thereof. (L S.B , A.L S.B. 16, A.L S.B. 452, A.L H.B. 343) *Section was repealed by S.B. 52 A, Completion of the program and eligibility to take NCLEX for licensure. Graduates of the Practical Nurse Program are eligible to apply to the Missouri State Board of Nursing for permission to take the NCLEX-PN Examination upon completion of the program. Completion of the program does not guarantee eligibility to take the NCLEX-PN Examination. This is determined by the State Board of Nursing. 17. Qualifications for Applying for a Nursing License An applicant for license to practice as a licensed practical nurse shall: 1. Submit a written application on the forms to the State Board of Nursing furnished to the student (done after admittance to the program). 2. Be of good moral character. (Fingerprinting & Criminal background check is required.) 3. Have high school diploma or passed equivalency exam (G.E.D.). 4. Have successfully completed a program at an accredited school of nursing. 5. Have completed a course approved by the board on the role of the practical nurse. 6. Shall submit evidence of proficiency in the English language if applicant is from a non-english speaking country. 7. Be approved by the State Board of Nursing. 8. Be required to pass the State Board of Nursing Examination (NCLEX-PN). 18. Refund Policy for Financial Aid Recipients Students who have received federal financial aid funds are required to earn these funds by attending classes through at least 60% of the period of enrollment. Students who fail to meet this guideline will be required to repay all or a portion of their financial aid. 5

8 This policy, established by the U.S. Department of Education through the Higher Education Act of 1965, affects students who have received assistance through the following federal financial aid programs: Pell Grant Stafford Subsidized and Unsubsidized Loans Attendance information is collected on a daily basis. If you are not attending classes it is important to officially withdraw to determine the official withdrawal date. The official withdrawal date determines the amount you may be required to repay the federal government for financial aid received which was intended to finance educational costs while you are attending school. Satisfactory Academic Progress for Financial Aid Purposes To maintain eligibility for financial aid, a student must meet Satisfactory Academic Progress: maintain a C average in each course. Failure to meet Satisfactory Academic Progress may result in being placed on Financial Aid Warning or Probation. Failure to return to Satisfactory Academic Progress after being placed on Warning or Probation status could cause a disruption in a student s eligibility to receive Title IV Financial Aid funding. Please see Gina Duckett in regards to Financial Aid questions 19. Required minimal functional ability categories and representative activities/attributes: a. Gross Motor Skills 1. Move within confined spaces 2. Sit and maintain balance 3. Stand and maintain balance 4. Reach above shoulders (e.g., IV poles) 5. Reach below waist (e.g., plug electrical appliance into wall outlets) b. Fine Motor Skills 1. Pick up objects with hands 2. Grasp small objects with hands (e.g., IV tubing, pencil) 3. Write with pen or pencil 4. Key/type (e.g., use a computer) 5. Pinch/pick or otherwise work with fingers (e.g., manipulate a syringe) 6. Twist (e.g., turn object/knobs using hands) 7. Squeeze with finger (e.g., eye dropper) c. Physical Endurance 1. Stand (e.g., at client side during surgical or therapeutic procedure) 2. Sustain repetitive movements (e.g., CPR) 3. Maintain physical tolerance (e.g., work entire shift) d. Physical Strength 1. Push and pull 25 pounds (e.g., position clients) 2. Support 25 pounds of weight (e.g., ambulate client) 3. Lift 25 pounds (e.g., pick up a child, transfer client) 4. Move light objects weighing up to 10 pounds (e.g., IV poles) 5. Move heavy objects weighing from 11 to 50 pounds 6. Defend self against combative client 7. Carry equipment/supplies 8. Use upper body strength (e.g., perform CPR, physically restrain a client) 9. Squeeze with hands (e.g., operate fire extinguisher) e. Mobility 1. Twist 2. Bend 3. Stoop/squat 4. Move quickly (e.g., response to an emergency) 5. Climb (e.g., ladders/stools/stairs) 6. Walk 6

9 f. Hearing 1. Hear normal speaking level sounds (e.g., person-to-person report) 2. Hear faint voices 3. Hear faint body sounds (e.g., blood pressure sounds, assess placement of tubes) 4. Hear in situations when not able to see lips (e.g., when masks are used) 5. Hear auditory alarms (e.g., monitors, fire alarms, call bells) g. Visual 1. See objects up to 20 inches away (e.g., information on a computer screen, skin conditions) 2. See objects up to 20 feet away (e.g., client in a room) 3. See objects more than 20 feet away (e.g., client at end of hall) 4. Use depth perception 5. Use peripheral vision 6. Distinguish color (e.g., color codes on supplies, charts, bed) 7. Distinguish color intensity (e.g., flushed skin, skin paleness) h. Tactile 1. Feel vibrations (e.g., palpate pulses) 2. Detect temperature (e.g., skin, solutions) 3. Feel differences in surface characteristics (e.g., skin turgor, rashes) 4. Feel differences in sizes, shapes (e.g., palpate vein, identify body landmarks) 5. Detect environmental temperature (e.g., check for drafts) i. Smell a. Detect odors from client (e.g., foul smelling drainage, alcohol, etc.) b. Detect smoke c. Detect gases or noxious smells j. Reading a. Read and understand written documents (e.g., policies, protocols) k. Arithmetic Competence 1. Read and understand columns of writing (e.g., flow sheet, charts) 2. Read digital displays 3. Read graphic printouts (e.g., EKG) 4. Calibrate equipment 5. Convert numbers to and/or from the Metric System 6. Read graphs (e.g., vital sign sheets) 7. Tell time 8. Measure time (e.g., count duration of contractions, etc.) 9. Count rates (e.g., drips/minute, pulse) 10. Use measuring tools (e.g., thermometer) 11. Read measurement marks (e.g., measurement tapes, scales, etc.) 12. Add, subtract, multiply, and/or divide whole numbers 13. Compute fractions (e.g., medication dosages) 14. Use a calculator 15. Write numbers in records l. Emotional Stability 1. Establish therapeutic boundaries 2. Provide client with emotional support 3. Adapt to changing environmental/stress 4. Deal with the unexpected (e.g., client going bad, crisis) 5. Focus attention on task 6. Monitor own emotions 7. Perform multiple responsibilities concurrently 8. Handle strong emotions (e.g., grief) 7

10 m. Analytical Thinking 1. Transfer knowledge from one situation to another 2. Process information 3. Evaluate outcomes 4. Problem solve 5. Prioritize tasks 6. Use long term memory 7. Use short term memory n. Critical Thinking 1. Identify cause-effect relationships 2. Plan/control activities for others 3. Synthesize knowledge and skills 4. Sequence information o. Interpersonal Skills 1. Negotiate interpersonal conflict 2. Respect differences in clients 3. Establish rapport with clients 4. Establish rapport with co-workers p. Communication Skills 1. Teach (e.g., client/family about health care) 2. Explain procedures 3. Give oral reports (e.g., report on client s condition to others) 4. Interact with others (e.g., health care workers) 5. Speak on the telephone 6. Influence people 7. Direct activities of others 8. Convey information through writing (e.g., progress notes) 20. Admission Requirements/Criteria: a. Complete & sign application forms in application packet & submit by deadline. b. Satisfactorily complete pre-entrance exam (TEAS-V test). c. Provide high school diploma or GED transcripts(& college, if applicable). d. Provide copy of marriage license or divorce decree: birth certificate; drivers license; social security; immunization record; and proof of address (utility bill) e. Provide three (3) written references using the forms provided. f. Satisfactory completion of criminal background check. 8

11 CURRICULUM SEQUENCE Semester I Course Name Course Hours Personal and Vocational Concepts 38 Anatomy and Physiology 95 Nutrition 40 Geriatrics 35 Pharmacology I 48/49 Fundamentals of Nursing 150/141 Intravenous Therapy 40/8 Total Theory Hours for Level I = 446 Total Clinical Hours for Level I = 198 TOTAL Hours for Level I = 644 9

12 Semester II Course Name Course Hours Mental Health Nursing 45/28 Pharmacology II 72 Medical/Surgical 150/104 Obstetrics 45/28 Pediatrics 50/28 Leadership and Management 38/56 Observation and Review/exit testing 30/42 Total Theory Hours for Level II Total Clinical Hours for Level II TOTAL Hours for Level II TOTAL PROGRAM HOURS for Semester I & II 1360 Sequence of courses are subject to change 10

13 Poplar Bluff TCC PRACTICAL NURSE PROGRAM REQUEST FOR ACCOMMODATION INTRODUCTION If you have a physical or mental impairment that substantially limits a major life activity, you may be eligible for accommodations in the testing process which will ensure that the test accurately reflects your skills, knowledge and abilities. Attempts will be made to provide a reasonable accommodation which will allow you to demonstrate your abilities. Attempts will allow you to demonstrate your abilities. Notify us prior to the start of school if you need special accommodations so that we may prepare for them. UNDERLYING PRINCIPLES Poplar Bluff TCC, Practical Nurse Program may approve appropriate exam modifications which are psychometrically sound and safeguard the fairness and security of the testing process for all applicants. The Americans and Disabilities Act has encouraged applicants of nursing programs to identify the essential abilities needed by nurses to practice safely. The applicants of nursing programs must be aware of the abilities required for safe nursing practice and of any personal limitations with respect to these abilities. Applicants of the nursing program should either make or request the accommodations needed to practice nursing safely. DESCRIPTION OF ACCOMMODATIONS REQUEST REVIEW & APPROVAL PROCESS All requests for exam modifications from applicants must be accompanied by the following: A letter of diagnosis from an appropriate health professional. The diagnosis must include a detailed rationale justifying why the requested accommodation is necessary and appropriate for the diagnosed disability. AND A letter from the applicant requesting the accommodations and detailing the specific accommodations. After the application and all documentation have been received, the program director, adult counselor and vocational education director will review the request and inform the applicant of their decision. STATEMENT Only physical or mental impairments that substantially limit one or more major life activities are disabilities subject to the protection of the Americans with Disabilities Act (ADA). Almost everyone experiences some apprehension before taking an important examination. Careful diagnosis is required to address the issue of what point normal anxiety constitutes a disability protected under ADA. Test anxiety, anxiety or phobia without precise diagnosis, may not constitute a disability within the meaning of ADA for the threshold reason that such terms are not recognized physiological or psychological impairments which substantially limits a major life activity. For more information or request accommodations, please contact the Poplar Bluff TCC, Practical Nurse Program. 11

14 Poplar Bluff TCC PRACTICAL NURSE PROGRAM Admission Rating System Applicant Name Judge # The following is the admission rating which will be utilized for rating each eligible applicant: Possible Points Description of Rating Points Received 0-4 Application Packet: Completeness (2) & Legibility (2) 0-7 References: Content of Recommendation (Max. of 2 pts each) Add 1 point for having all 3 recommendations 0-14 Interview: each item scored 0-2 Appropriately dressed: Communication Skills: Punctual: Problem Solving: Attitude: Understanding Nursing: Sincerity in Pursing a Nursing Career: 0-25 TEAS Reading Score: 100% = % = % = % = %= % = % = % = % = %= % = % = % = % = %= % = % = % = % = %= % = % = % = % = %=1 <51% = TEAS Math Score % = % = % = % = % = % = % = % = % = % = % = % = % = % = % = % = % = % = % = % = 1 < 40% = TEAS Science Score: % = % = % = % = % = % = % = % = % = % = % = % = % = % = % = 1 < 40% = TEAS English Score: % = % = % = % = % = % = % = % = % = % = % = % = % = % = % = 1 < 40% = 0 Total Points = 100 Total Points Received /100 12

15 Confidential Release Waiver Personal references are given assurance of confidentiality. For this reason we are requesting the following waiver agreement be signed. This is necessary in order to comply with Federal Law PL93-380, regarding confidential letters and statements of recommendations submitted by the references on your behalf. Agreement I, hereby waive my right to see the personal/professional letters of reference from people I have listed as references on my application for admission to Poplar Bluff TCC, Practical Nurse Program. I do give permission for the selection committee to have full access to this confidential information during the admission process. Criminal Background Check Authorization I understand that my acceptance into the program is contingent upon meeting all admission requirements including a satisfactory Criminal Background Screening. Signature Date 13

16 Poplar Bluff Technical Career Center Application for Admission - Postsecondary Programs 3203 Oak Grove Road Poplar Bluff, MO (fax) School of Practical Nursing School of Cosmetology Return this completed application and the appropriate non-refundable application fee. Make check payable to PBTCC. The application fee covers the cost of admission examinations and background check. Applications are not processed or considered complete until both fee and application are received. Completion of this application does not constitute admission to the program of study for which applicant is applying. Part 1 Personal Information Social Security No. / / Name Last First Middle Jr/Sr Maiden/Alias Last First Middle Jr/Sr Address City State Zip Telephone - Home: - - Telephone Cell - - Business: Date of Birth / / Does student use language other than English? If so, what language: Part 2 Cosmetology Application fee $25 Program Choice Clearly mark the desired program of study. Cosmetology/Manicure August Class - Applications accepted March 1 through May 1. Cosmetology/Manicure February Class - Applications accepted September 1 through November 1 Cosmetology/Manicure Additional Hours - See program coordinator for application submission information. Cosmetology Instructor Training - See program coordinator for application submission information. Esthetician - Applications accepted September through October 1 Manicure - Applications accepted January 1 through March 1 Practical Nursing Application fee $50 Applications will be accepted December 1 through March 1. Practical Nursing Program Technology & Industry Application fee $25 Applications will be accepted March 1 until June 30. After June 30 applications will only be accepted for programs with available openings. Automotive Collision Repair Automotive Technology Building Trades Computer Maintenance Technology Culinary Arts Welding Computer Graphics & Print Technology Heating, Ventilation, Air Conditioning & Refrigeration (HVACR) Part 3

17 Emergency Information In case of emergency, please notify: Name Relationship to Student Address City, State, Zip Home/Cell Phone Work Phone List any medical conditions PBTCC staff may need to be aware of: In the event of an emergency I authorize Poplar Bluff Technical Career Center personnel in charge to use their discretion regarding emergency procedures. Student Signature Date Part 4 Gender: Male Female Student Status Information (the following information is optional) Marital Status: Single Married Divorced Widow/Widower Ethnic Description: Nonresident Alien Asian Black, Non-Hispanic Hispanic American Indian or Alaskan Native White, Non-Hispanic Pacific Islander Two or More Races Race/Ethnicity Unknown other: I am eligible for the A+ Scholarship: Yes No I have received a bachelor s degree: Yes NO I am eligible and will receive funding from the following agency to pay educational expenses: VA Benefits Vocational Rehabilitation WIA TRA Private Company name of company Other: Please list the name, address and social security number of the person eligible to claim the tax credits associated with the payment of tuition and related fees: Name: Social Security Number Address City Zip Part 5 Education Information and Work Experience Name of high school: City State Graduated (year) or Will Graduate (year) GED (year) Certificate No. Official high school transcript or GED scores must be forwarded to PBTCC to fully complete admission process. Other Education Beyond High School Official post-secondary school transcript must be forwarded to PBTCC to fully complete admission process. Name of School City & State Degree/Certificate Dates of Earned Attendance Have you ever experienced disciplinary or academic probation while attending a postsecondary institution of learning? If yes, please attach detailed explanation. Work Experience List work experiences related to your field of study. Include experiences you feel are of benefit to you in your chosen field of study. Employer Position/Job Title Years/Months Job Held

18 Part 6 TO BE COMPLETED BY ALL APPLICANTS Have you ever been arrested and convicted of a felony or misdemeanor? If yes, please explain. My signature below gives the Poplar Bluff Technical Career Center permission to perform a background check. I understand that my Social Security number and other personal data provided on this enrollment application may be used as an identifier. I further understand that the misrepresentation or omission of facts called for is cause for non admittance or dismissal from a Poplar Bluff Technical Career Center program of study. Signature of Applicant Date The Poplar Bluff Technical Career Center is an Equal Opportunity Employer and operates educational programs which do not discriminate on the basis of age, race, color, creed, religion, nationality origin, sex, marital status or handicap. The School district is prohibited from discriminatory practices by Title VI and Title VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act, Title II of Americans with Disabilities Act of 1990 and various state laws and regulations. Return completed application, including the completed request for Criminal Record Check form and appropriate application fee to: Poplar Bluff Technical Career Center 3203 Oak Grove Road Poplar Bluff, MO Part 7 Functional Abilities Statement The Poplar Bluff Technical Career Center programs require certain functional abilities a student must be able to do, possess, or be able to be taught in order to successfully complete the programs of study and perform in the chosen career fields. Refer to admissions section in the student catalog for the list of functional abilities required of students admitted into these programs. I certify that I am physically and mentally able to perform the usual duties and functions associated with those of a nurse or cosmetologist and/or that I possess the capability to learn functional abilities as listed in student catalog in order to fulfill program requirements. Signature of Applicant Date APPLICATION CHECKLIST Application - Date Received: Application Fee Paid? yes no Amount Paid $ High School Transcript or GED scores; College Transcript if applicable; Proof of Immunizations; Background Check Completed; Credentials Received: birth certificate marriage license driver s license Proof of Residency: In-District Out-of-District For Office Use Only Do Not Write In This Area

19 Poplar Bluff Technical Career Center Applicant Professional Reference Form I,, DOB have applied for entrance to the Poplar Bluff Technical Career Center Cosmetology/Practical Nursing (circle one) program and hereby give my permission to release this information. Name of person completing this form (please print): Date How long have you known the applicant? In what capacity or relationship to the applicant are you completing this reference? (Mark all that apply) Employer Immediate Supervisor Co-worker Friend Counselor Pastor/Priest Teacher Health Care Provider Relative From your experience with this individual rate the following characteristics. Check one level of performance for each category. EXCELLENT GOOD FAIR POOR 1. INTEGRITY 2. DEPENDABILITY 3. PUNCTUALITY 4. INITIATIVE 5. MORAL/ETHICAL CHARACTER 6. INDUSTRIOUSNESS 7. GROOMING Do you know of any physical or emotional handicap that would influence this individual s performance in their chosen program of study? YES NO If so, please specify Would you employ this individual for a position which requires responsibility and stability? YES NO If no, please state reason: Would you recommend to the Poplar Bluff Practical Nurse Program that this person be admitted to the program? YES NO Additional Comments: In order that the applicant may be considered for admission, please complete this form and return it to the school at your earliest convenience. Please DO NOT GIVE it to the applicant. The applicant WILL NOT be seeing this completed form at any time and it will be destroyed after the application process has been completed. All information will be kept confidential. Feel free to contact the school for any further information. Signature of Person Completing Form Address State Zip School Address: Poplar Bluff Practical Nurse Program 3203 Oak Grove Road Poplar Bluff, MO (573) jolonvaughn@pb.k12.mo.us

20 Poplar Bluff Technical Career Center Applicant Professional Reference Form I,, DOB have applied for entrance to the Poplar Bluff Technical Career Center Cosmetology/Practical Nursing (circle one) program and hereby give my permission to release this information. Name of person completing this form (please print): Date How long have you known the applicant? In what capacity or relationship to the applicant are you completing this reference? (Mark all that apply) Employer Immediate Supervisor Co-worker Friend Counselor Pastor/Priest Teacher Health Care Provider Relative From your experience with this individual rate the following characteristics. Check one level of performance for each category. EXCELLENT GOOD FAIR POOR 8. INTEGRITY 9. DEPENDABILITY 10. PUNCTUALITY 11. INITIATIVE 12. MORAL/ETHICAL CHARACTER 13. INDUSTRIOUSNESS 14. GROOMING Do you know of any physical or emotional handicap that would influence this individual s performance in their chosen program of study? YES NO If so, please specify Would you employ this individual for a position which requires responsibility and stability? YES NO If no, please state reason: Would you recommend to the Poplar Bluff Practical Nurse Program that this person be admitted to the program? YES NO Additional Comments: In order that the applicant may be considered for admission, please complete this form and return it to the school at your earliest convenience. Please DO NOT GIVE it to the applicant. The applicant WILL NOT be seeing this completed form at any time and it will be destroyed after the application process has been completed. All information will be kept confidential. Feel free to contact the school for any further information. Signature of Person Completing Form Address State Zip School Address: Poplar Bluff Practical Nurse Program 3203 Oak Grove Road Poplar Bluff, MO (573) jolonvaughn@pb.k12.mo.us

21 Poplar Bluff Technical Career Center Applicant Professional Reference Form I,, DOB have applied for entrance to the Poplar Bluff Technical Career Center Cosmetology/Practical Nursing (circle one) program and hereby give my permission to release this information. Name of person completing this form (please print): Date How long have you known the applicant? In what capacity or relationship to the applicant are you completing this reference? (Mark all that apply) Employer Immediate Supervisor Co-worker Friend Counselor Pastor/Priest Teacher Health Care Provider Relative From your experience with this individual rate the following characteristics. Check one level of performance for each category. EXCELLENT GOOD FAIR POOR 15. INTEGRITY 16. DEPENDABILITY 17. PUNCTUALITY 18. INITIATIVE 19. MORAL/ETHICAL CHARACTER 20. INDUSTRIOUSNESS 21. GROOMING Do you know of any physical or emotional handicap that would influence this individual s performance in their chosen program of study? YES NO If so, please specify Would you employ this individual for a position which requires responsibility and stability? YES NO If no, please state reason: Would you recommend to the Poplar Bluff Practical Nurse Program that this person be admitted to the program? YES NO Additional Comments: In order that the applicant may be considered for admission, please complete this form and return it to the school at your earliest convenience. Please DO NOT GIVE it to the applicant. The applicant WILL NOT be seeing this completed form at any time and it will be destroyed after the application process has been completed. All information will be kept confidential. Feel free to contact the school for any further information. Signature of Person Completing Form Address State Zip School Address: Poplar Bluff Practical Nurse Program 3203 Oak Grove Road Poplar Bluff, MO (573) jolonvaughn@pb.k12.mo.us