Nursing Program Application

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1 Nursing Program Application All nursing programs start in August and complete in May Online and on-campus ADN Program (Associate Degree in Nursing) Application Deadline April 1 All prerequisite courses must be completed no later than May 15 Transcripts from PN/Paramedic certificate granting institution by June 1 LPN/Paramedic - License/Certificate available for verification by July 1 TEAS test scores by May 15 On-campus PN (Practical Nurse Program) Located at Pratt Community College and Winfield Campus at the Cowley Community College Allied Health Center Application deadline April 1 All prerequisite courses completed no later than May 15 Transcripts from prerequisite schools by June 1 CNA Certificate available for verification by June 1 TEAS test scores by May 15 International Students: F-1 Visa students must have met International Student requirements as identified on the website at: prattcc.edu/student-services/international Non-US Citizens: Permanent Residency status students must provide a clear and legible copy of the valid permanent card/certificate with the application. Applications without documentation will not be considered. All students: To be considered for the program, your nursing application MUST: Be Complete Be Legible Be accurate Be submitted on or prior to the deadline For additional information: prattcc.edu

2 Nursing Application Form Office use only: Program applied for Student ID Prior to completing the nursing application form, students must complete a admissions application for the college. Please review the admission and legal requirements for LPN/RN very carefully. A one-time $25 non-refundable fee must accompany application. Application will not be processed until fee is received. Personal Information - ALL information MUST be completed or won t be processed Last Name First Name Middle Name Maiden Name Other Last Names (That may appear on transcripts) Date of Birth (MM/DD/YYYY) Street Address City County State Zip Code ( ) ( ) Home phone cell phone address (required) Alternate address Are you a Kansas Resident? Yes No Are you a US citizen? Yes No Persons with F-1 or preeminent residency or a certificate of nationalization If you have permanent residency, F-1 VISA, or have obtained US Citizenship you MUST provide supporting documentation before you will be considered for our program. I have provided the following: Permanent Residency F-1 Visa(I-20) and TOEFL scores US Citizenship documents I agree that the information I have provided is correct. Yes No Program Applying for: Only one (1) program may be chosen. Winfield PN Program on-campus Winfield ADN Program on-campus Pratt PN Program on-campus Pratt ADN Completion Program online Pratt ADN Completion Program on-campus On-campus and online programs will start in August August 2016 August 2017 August 2018

3 Education ALL official college transcripts including official high school transcripts are required for the following: - Nursing Applicants will not be evaluated for program until ALL official transcripts have been received - Financial Aid cannot be completed until all official transcripts have been received Where did you receive your high school diploma, GED, or home school certificate? If received diploma, name of high school: Year of graduation: List all colleges and universities attended: Prerequisites required All grades must be a C or better and must be completed prior to admissions requirement deadline date. Please note the higher pre-req GPA the better your chances are at getting selected. Required Courses: English Composition I General Psychology Developmental Psychology Microbiology with lab (BIO 165) - 5 credit hours (5 year expiration) Anatomy & Physiology with lab - 5 credit hours (5 year expiration) OR A&P I + A&P II OR Human Anatomy + Human Physiology Intermediate Algebra or higher Recommended Courses: Chemistry Biology College Algebra Pharmacology (If received your LPN more than three years ago) We have found that students who take and successfully complete the recommended courses are more likely to succeed in the program. Nursing application and fee must be mailed to: Pratt Community College Att: Nursing Admissions 348 NE SR 61 Pratt, KS 67124

4 Prerequisites required Pre-Requisites (Transferability to be determined by the Registrar) Status (To be considered complete must have a C or better) Where you completed the course Date course was or will be completed Anatomy & Physiology w/ Lab (Minimum 5 hour course) 5 year expiration CPR for Healthcare Providers Developmental Psychology English Comp I General Psychology Kansas Certified Nurse Aid Certification Kansas License for Practical Nursing Microbiology w/ Lab (Minimum 5 hour course) 5 year expiration This section MUST be completed and turned in with application materials.

5 Qualifications ALL information is required or application will NOT be processed List licensure or certification: Name as it appears on license/certificate How many times did you take the state boards for LPN or Paramedic? We must receive an official transcript showing program completion for LPN and Paramedic. Legal Qualifications ALL information is required or application will NOT be processed Have you been convicted of a misdemeanor or felony? Yes No If yes, see Legal Qualifications before applying to this program to see if you are eligible. You may find the Legal Qualifications at the following website: Terms: I certify that the information provided is correct and complete. I understand that submission of false information and/or failure to submit supporting transcripts is grounds for denial of admissions, re-enrollment, or immediate suspension if enrolled. If accepted as a student at, I agree to abide by the rules and regulations of the college regarding conduct, financial and other obligations. I have read the admission requirements, the legal qualifications for LPN/RN Licensure, and the estimated cost sheet. I affirm my intention to meet these requirements and agree to immediately report any change of status related to information on this application. I agree with these terms: Yes No Student Signature Today s Date Pratt Community College is an equal opportunity employer and does not discriminate on the basis of any characteristic protected by law in admission, recruitment, treatment or employment in its programs and activities. Pratt Community College hires only U.S. citizens and aliens lawfully authorized to work in the United States. If you have any questions, please contact the Director of Personnel, Pratt Community College, 348 NE SR 61, Pratt, KS 67124, Title IX/Section 504 Coordinator. Pratt Community College reserves the right to change program dates and times. Completion of admission checklist items makes candidates eligible for consideration by the selection committee. College Admission does not guarantee admission into the Nursing Program.

6 Nursing Application Fee Form 348 NE SR 61 Pratt, KS prattcc.edu (620) Prior to completing the nursing application form, students must complete a admissions application for the college. Please review the admission and legal requirements for LPN/RN very carefully. A one-time $25 non-refundable fee must accompany application. Application will not be processed until fee is received. Personal Information Last Name First Name Middle Name Date of Birth (MM/DD/YYYY) Street Address City County State Zip Code Home phone cell phone address Check here if address listed above is permanent address Payment Information: Check Money Order Credit/Debit If you wish to be by credit or debit card, please call one of the phone numbers listed below to submit payment and fax application. application and fee forms must be mailed to: Pratt Community College Nursing Admissions 348 NE SR 61 Pratt, KS Fax: (620) Phone: (620) or (620) I certify all information has been provided and is correct to the best of my knowledge. I understand that in order to process my nursing application, must receive a one-time non-refundable $25 nursing application fee. Student Signature Date For official use Date fee received:

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