Application for Admission to the Master of Science (M.S.) Program in Nursing

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1 Application for Admission to the Master of Science (M.S.) Program in Nursing Date of application When do you plan to begin your studies? Academic year: Term: Fall Spring Summer Office Use: ID # Appl. fee Date I am interested in the following M.S. Program in Nursing Track (check one): Nursing Administration Nursing Education Clinical Nurse Leader Adult-Gerontology Primary Care Nurse Practitioner Adult-Gerontology Acute Care Nurse Practitioner Undecided Biographical and Contact Information Name Have you ever enrolled in or taken courses previously through any division of Moravian College? Yes No Optional This information will be used for statistical purposes only and will not affect decisions concerning attendance at Moravian College. Birth date Social Security Number - - Address Phone numbers: Home Cell Work address If you are a veteran, please indicate your File # C What is your citizenship? U.S. citizen Permanent resident (green card) Non-resident alien Gender F M Hispanic or Latino Yes No Ethnic group (Choose one or more) American Indian, Native American, or Alaskan Native Asian Black or African-American Native Hawaiian or other Pacific Islander White Moravian College encourages persons with disabilities to participate in its programs and activities. If you anticipate needing any type of accommodation or have questions about the physical access provided, please contact us at at least one week prior to the event. Moravian College is accredited by the Middle States Association of Colleges and Secondary Schools and is an institutional member of the Association for Continuing Higher Education. We are also members of the Association of Collegiate Business Schools and Programs (ACBSP) and the Association to Advance Collegiate Schools of Business (AACSB) International. Moravian College is a welcoming community that embraces and values the diversity of all members of the campus community. We accept the uniqueness of all individuals, and we seek to cultivate an environment that respects, affirms, and defends the dignity of each member of the community. Moravian College does not discriminate against any person based on actual or perceived race, color, sex, religion, ancestry, genetic information, national origin, sexual orientation, gender identity or expression, familial status, marital status, age, veteran status, mental or physical disability, use of guide or support animals and /or mechanical aids, or any other basis protected by applicable federal, state, or local laws. The Comenius Center office, however, reserves the right to deny registration privileges to an individual whose conduct might interfere with the College s exercise of its educational mission or its responsibility to its members. Inquiries concerning this policy may be directed the 1 Vice President of Administration, Moravian College, Bethlehem, PA 18018,

2 RN Licensure Information State: Registration # Renewal Date Educational History Please list all post-secondary educational institutions that you have attended. Begin with the one you attended most recently. If any of these records are in another name, check here and list that name below: Name of Institution Location City/State Dates attended mm/yy-mm/yy Received degree? Please specify. degree mm/yy awarded major or field of study Current Employment Employer Address City State Zip Position / Title For how many years have you held this position? How long have your worked for this employer? 2

3 TOEFL Students who do not consider English to be their primary language are required to submit official scores of a recent TOEFL (Test of English as a Foreign Language) examination to the. A minimum score of 550 is required for the paper-based test and 260 for the computer-based test. Recommendations Recommendation forms are required from two (2) professional references who can authoritatively address your professional capabilities and preparation for professional graduate study. At least one recommendation must come from a nursing supervisor. Please indicate the names and contact information for your references. Reference 1 Reference 2 Name Address Phone Each recommender must submit recommendation form in a sealed envelope with his or her signature across the seal. Please provide a recommendation form and a stamped, pre-addressed envelope to each recommender. Envelopes should be addressed to: 1200 Main Street Bethlehem, PA Written Statement of Professional Goals In addition, please submit a cover letter and a personal statement of professional goals, including reasons for nursing graduate study in the program to which you are applying. Describe in the written statement how a Moravian College Master of Science degree with a major in Nursing will enable you to achieve these goals. The personal statement must address characteristics and experiences that have made you and will make you successful in Nursing. This essay should be written in a scholarly manner and be approximately 500 words in length, wellorganized, typewritten, and double-spaced. This personal statement is an essential component of your application and is used by the Admissions Team to evaluate writing competency and to identify candidates whose abilities and goals are congruent with the goals of the nursing program. 3

4 Resume Along with this completed application form, please submit a current professional resume. In this resume include 1. Work experience with dates of employment, distinguishing between full time, part-time, and temporary employment, and including descriptions of duties and responsibilities. 2. Internships 3. Educational institutions attended, dates of enrollment, major area(s) of study and degree(s) earned 4. Awards, honors, and recognitions received 5. Significant college, community/volunteer, leadership, and professional activities in which you have participated. Completing Your Application 1. Resume 2. Written Statement of Professional Goals 3. Application Fee. A $40 fee must accompany this application. 4. Official Transcripts from all institutions listed on page 2 of this application 5. Letters of Recommendation (2) NOTE: A pre-admission interview is required of all applicants to Nurse Practitioner Programs Items 1-4 should be submitted together. Items 5-7 should be sent directly to us from sources listed. All materials should be sent to: 1200 Main Street Bethlehem, PA Attestations Moravian College supports efforts to maintain a safe and supportive environment for the entire college community. For that reason, we ask the following questions. Please be assured that a yes answer to either question will not, automatically, disqualify you from admission to the Comenius Center. 1. Have you ever been subject to disciplinary action (suspension, dismissal, other) at any post-secondary institution? No Yes 2. Have you ever been convicted of a crime classified as a misdemeanor or felony, or are criminal charges pending against you? No Yes If you answered Yes to either of the preceding questions, please provide details. You may do so either in a written statement or by meeting in person with the Dean of the Comenius Center. I affirm that all information provided on this application is true and accurate to the best of my knowledge. I understand that intentional falsification is grounds for termination from the program. By registering for courses, I agree to abide by all applicable Moravian College policies. (Signature) (Date) 4

5 Moravian College Department of Nursing 1200 Main Street Bethlehem, Pennsylvania Master of Science (M.S.) Program in Nursing Confidential Recommendation Statement Applicant s Name: Intended track: Nursing Administration Nursing Education Clinical Nurse Leader Undecided Adult-Gerontology Primary Care Nurse Practitioner Adult-Gerontology Acute Care Nurse Practitioner For Applicant s Signature In accordance with the Family Education Rights and Privacy Act of 1974, you, the applicant, have the right to review this recommendation if you enroll in the Master of Science (M.S.) Program in Nursing. This Act also provides that you may waive your right by signing the statement below. I hereby waive do not waive my right of access to this recommendation. Signature: Date: / /20 Failure to complete and sign this section will be considered an expressed waiver of your rights. For Recommender The person listed above has applied for admission to the Moravian College M.S. Program in Nursing and has given your name as a reference. The M.S. Program in Nursing is a graduate program designed for R.N. s with professional interests and goals in one of three program tracks Nursing Administration, Nursing Education, and Clinical Nurse Leader. Please provide us with your candid evaluation of this individual s areas of strength and needs for growth, as well as your assessment of the candidate s ability to be successful in our graduate program. Your personal experience with the candidate provides a perspective we find valuable in our assessment of his or her application for admission. We value your personal and candid opinion of his or her potential to successfully complete this program. Please use only this form and return it directly to the Comenius Center in an envelope sealed by you and signed over the envelope flap. Send to: 1200 Main Street, Bethlehem, PA Thank you for taking the time to share your insights with us. Recommender s Name: Please Print Position/Title: Organization: Telephone: ( ) -- How long have you known the applicant? months/years In what context have you known the Applicant? 5

6 What are the applicant s particular strengths? What areas of growth opportunity do you see in the applicant? 6

7 Assessment of Applicant s Abilities Please rate the applicant by putting a check mark in the appropriate box under the following descriptors: Superior, Excellent, Satisfactory, Fair, Weak, or Inadequate Opportunity to Observe. Inadequate Opportunity to Observe Applicant Assessment Superior (Top 5%) Excellent (Top 10%) Satisfactory (Top 25%) Fair (Top 50%) Weak (Lower 50%) Performance or potential as a creative or innovative leader in nursing Productivity in independent work or projects Ability to create and communicate a vision Intellectual aptitude or potential Contribution to practice dilemmas with a culture of inquiry and best-practice solutions Management of projects or programs that promote safe and quality outcomes Adherence to professional nursing standards in guiding ethical decision-making Accountability in developing quality and performance initiatives in multidisciplinary settings Advocacy for nursing s cultural competence in the organization and community settings Proficiency in use of technology, including Internet and word processing Effectiveness in oral expression Effectiveness in written communication Flexibility and adaptability to change Overall potential for success in graduate education Additional Comments (you may attach an additional page if your comments exceed the space provided): Recommender s Signature: Date: / / 7

8 Moravian College Department of Nursing 1200 Main Street Bethlehem, Pennsylvania Master of Science (M.S.) Program in Nursing Confidential Recommendation Statement Applicant s Name: Intended track: Nursing Administration Nursing Education Clinical Nurse Leader Undecided Adult-Gerontology Primary Care Nurse Practitioner Adult-Gerontology Acute Care Nurse Practitioner For Applicant s Signature In accordance with the Family Education Rights and Privacy Act of 1974, you, the applicant, have the right to review this recommendation if you enroll in the Master of Science (M.S.) Program in Nursing. This Act also provides that you may waive your right by signing the statement below. I hereby waive do not waive my right of access to this recommendation. Signature: Date: / /20 Failure to complete and sign this section will be considered an expressed waiver of your rights. For Recommender The person listed above has applied for admission to the Moravian College M.S. Program in Nursing and has given your name as a reference. The M.S. Program in Nursing is a graduate program designed for R.N. s with professional interests and goals in one of three program tracks Nursing Administration, Nursing Education, and Clinical Nurse Leader. Please provide us with your candid evaluation of this individual s areas of strength and needs for growth, as well as your assessment of the candidate s ability to be successful in our graduate program. Your personal experience with the candidate provides a perspective we find valuable in our assessment of his or her application for admission. We value your personal and candid opinion of his or her potential to successfully complete this program. Please use only this form and return it directly to the Comenius Center in an envelope sealed by you and signed over the envelope flap. Send to: 1200 Main Street, Bethlehem, PA Thank you for taking the time to share your insights with us. Recommender s Name: Please Print Position/Title: Organization: Telephone: ( ) -- How long have you known the applicant? months/years In what context have you known the Applicant? What are the applicant s particular strengths? 8

9 What areas of growth opportunity do you see in the applicant? 9

10 Assessment of Applicant s Abilities Please rate the applicant by putting a check mark in the appropriate box under the following descriptors: Superior, Excellent, Satisfactory, Fair, Weak, or Inadequate Opportunity to Observe. Inadequate Opportunity to Observe Applicant Assessment Superior (Top 5%) Excellent (Top 10%) Satisfactory (Top 25%) Fair (Top 50%) Weak (Lower 50%) Performance or potential as a creative or innovative leader in nursing Productivity in independent work or projects Ability to create and communicate a vision Intellectual aptitude or potential Contribution to practice dilemmas with a culture of inquiry and best-practice solutions Management of projects or programs that promote safe and quality outcomes Adherence to professional nursing standards in guiding ethical decision-making Accountability in developing quality and performance initiatives in multidisciplinary settings Advocacy for nursing s cultural competence in the organization and community settings Proficiency in use of technology, including Internet and word processing Effectiveness in oral expression Effectiveness in written communication Flexibility and adaptability to change Overall potential for success in graduate education Additional Comments (you may attach an additional page if your comments exceed the space provided): Recommender s Signature: Date: / / 10

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