NORTHLAND PIONEER COLLEGE LICENSED PRACTICAL NURSE TO REGISTERED NURSE PROGRAM APPLICATION PACKET DEADLINE: OCTOBER 1

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1 LICENSED PRACTICAL NURSE TO REGISTERED NURSE PROGRAM APPLICATION PACKET DEADLINE: OCTOBER 1 All 8 prerequisites must be completed with a grade of C or better prior to Fall Admission into the Nursing Program. Courses: General Biology (BIO 181) Human Anatomy and Physiology I (BIO 201) Human Anatomy and Physiology II (BIO 202) Microbiology (BIO 205) Fundamental Chemistry (CHM 130) College Composition I (ENL 101) College Composition II (ENL 102) Pharmacology I (NUR 117) Date Completed Licensure: Must be a current LPN (Licensed Practical Nurse) and submit a copy of current Arizona License in good standing with the notarized application. A pre-admission HESI LPN Exit Exam will be required prior to spring admission with a passing score of 800 or higher. Submit the following items: Date Completed 1. The completed notarized application and the Notice of No Guarantee of Licensure/Certification forms. (This should be submitted as soon as possible, so that you can be contacted regarding your file.) 2. Copy of current Arizona LPN License. 3. Three professional or academic references submitted from someone who has served as your supervisor or instructor in a work or school setting. 4. A one page typed double spaced Personal Statement must be submitted with the application. The personal statement should address why you wish to return to school, what you have done to meet your goals, and what you bring to our nursing program. 5 Request OFFICIAL transcripts of the above courses from all previous Colleges you have attended sent to: Northland Pioneer College Nursing Programs P.O. Box 610 Holbrook, AZ (All materials must be sent to the above address. Any materials sent to the college without Nursing Programs in the address may become lost.) PUBLIC NOTICE OF NON-DISCRIMINATION: The College does not discriminate on the basis of race, color, national origin, religion, marital status, gender, age or disability in admission or access to, or treatment or employment in its educational programs or activities. District grievance procedures will be followed for compliance with Title IX and Section 504 requirements. The Affirmative Action Compliance Officer is Director of Personnel, 103 First Avenue at Hopi Drive, Holbrook, AZ 86025, The Section 504 Compliance Officer is the Coordinator of Disability Resources and Access, 1001 W Deuce of Clubs, Show Low, AZ 85901, The lack of English language skills will not be a barrier to admission and participation in vocational education programs.

2 LICENSED PRACTICAL NURSE TO REGISTERED NURSE CURRICULUM Required Courses/Licensure to gain Admission to the LPN to RN Program Before the student will be considered eligible to apply to the nursing program, all courses must be completed with a grade of C or higher. Credits BIO 181 General Biology 4 BIO 201 Human Anatomy & Physiology I 4 BIO 202 Human Anatomy & Physiology II 4 BIO 205 Microbiology 4 CHM 130 Fundamental Chemistry 4 ENL 101 College Composition I 3 ENL 102 College Composition II 3 NUR 117 Pharmacology I 2 28 Licensure: Must be a Current LPN (Licensed Practical Nurse) and must submit a copy of license prior to the spring admission. Required Courses to Complete the Nursing Program Spring Semester: Core Requirements Credits NUR 116 LPN RN Transitions 3 NUR 118 Pharmacology II 2 General Education Requirement PSY 240 Developmental Psychology 3 Total 8 Any of the above courses may be taken in conjunction with NUR 116. All of the above courses must be completed before admission into the 3 rd semester of the ADN program. Fall (3 rd ) Semester: Core Requirements NUR 221 Nursing III 8 General Education Requirement SOC 120 or ANT Total 11 Spring (4 th ) Semester: NUR222 Nursing IV 8 NUR 219 NCLEX Review Course 2 Total 10 All of the general education or non-nur courses may be completed before entering the program, but must be completed as listed above and no later than beginning of the next semester. IF THE COURSES ARE NOT COMPLETED AS STATED THE STUDENT CANNOT CONTINUE IN THE NURSING PROGRAM. All courses require a grade of "C" or better for advancement in the program

3 Transfer Students Nursing degree-seeking transfer student should submit official copies of previous college work to the Records & Registration Office. Students must include and complete the Request for Evaluation of Transfer Credits form. This form may be obtained from an Academic Advisor or the Record & Registration Office. Evaluated credits will aid advisement prior to enrolling in classes. Transfer students require a letter of recommendation from the director of their previous nursing program. LPN students must have a letter of recommendation from a former employment clinical supervisor. Petitions for Exceptions Students seeking exceptions to degree requirements should meet with an Academic Advisor for assistance in completing the petition forms. These forms accompanied by supporting information such as copies of transcripts, course descriptions, and articulation rules are forwarded to the Dean of Nursing and Allied Health. The Dean makes a recommendation and forwards the paperwork to the Registrar and Vice President for Learning for a final decision and distribution of the copies of the petition form. Transferability of Credits Students interested in transferring their credits to another Arizona public university should contact an Academic Advisor. NPC offers online access to The Arizona Course Applicability System (CAS) which offers helpful features that allow you to: See how your previous courses will transfer to public universities in Arizona Learn what community college courses transfer as specific university equivalents View transfer guides that outline university academic programs for community college students Research lists of community college courses that apply to university general education equivalents To access the Arizona Course Applicability System, visit their website at Placement Testing The nursing program is sincerely interested in student success. To ensure that students select courses appropriate for their skill level, placement testing for all mathematics, English, and general education courses is required. The nursing program requires minimal competency in Algebra by scoring a 46 on the COMPASS Algebra test or a 41 on the ASSET Elementary Algebra test or a 21 on the ACT Math test. The math test must be taken no more than one year prior to the application deadline date. Students should contact an Academic Advisor to begin the placement process. If you need academic accommodations for placement testing, contact the Disability Resource and Access Office. LPN to RN Alternative Learning Credit For the student who is a Licensed Practical Nurse (LPN), who wishes to enter the program to acquire the Associate of Applied Science in Nursing degree, the prerequisite requirements are identical to the multiple exit program. Students should meet with an NPC Academic Advisor and provide evidence of course content and classroom hours for their LPN training and submit this documentation to Records and Registration for determination of assessed credit for NUR 121, NUR 122, and NUR 125. This is necessary to receive a general overview of the options and processes that may need to be followed for any individual student s situation. Evaluation and approval of assessed course credit does not guarantee admission to the nursing program. Decisions regarding acceptance are determined by the nursing admission committee. Note: Additional fees apply for alternative credit by evaluation. Instructional Methods The Nursing Program uses a variety of instructional methods to facilitate learning. Face-to-face lecture experiences in the traditional classroom setting offer students live, interactive instruction. Low to moderate fidelity simulation laboratory classes allow students to practice skills and develop critical thinking processes in a safe, non-threatening environment. Clinical experiences take place in various health care agencies in and outside the college s district. Hours may vary from the class schedule depending on the clinical placement and travel will be required at times. In addition, overnight stays may be required. If you have concerns about your ability to fully participate in any instructional methods, contact the Dean and submit appropriate documentation of diagnosis and limitations to the Disability Resource Coordinator prior to enrollment.

4 NURSING PROGRAM DRUG SCREENING AND SUBSTANCE ABUSE PROCEDURES A pre-clinical drug screening is required for all student nurses. It is done during the first part of the semester prior to the student nurses clinical experiences. Students are given a twelve-hour or twentyfour hour notice to proceed with this drug screening (urine specimen). In addition, there is a For Cause substance abuse procedure for student nurses who exhibit mental or physical impairment due to use of alcohol, illegal or prescribed drugs while carrying out student nursing responsibilities in the college and health care settings. Both procedures are in the Nursing Student Handbook PHYSICAL EXAMINATION A physical examination with a statement that you are able to perform nursing essential functions is required prior to enrollment. An immunizations record will be required after admission to the Nursing Program and prior to starting any clinical rotations. CPR All students must have current, valid Healthcare Provider CPR certification prior to clinical rotations.

5 LICENSED PRACTICAL NURSE TO REGISTERED NURSE ESTIMATED STUDENT COST (Nursing and Gen. Ed. Courses included) For Arizona Residents Spring Semester Spring Semester Totals 1. Tuition $ $ NUR 116 Course Fees Books Media Fee st Year Total $ $ nd Year 1 st Sem 2 nd Sem Totals 1. Registration $ $ $ NUR Course Fees Books Media Fee $ NCLEX-RN nd Year Total $ $1, $2, Graduation Fee $ $ Pin $ $ Estimated Nursing Program Total $3, (Travel expenses may be required for clinicals.) PUBLIC NOTICE OF NON-DISCRIMINATION: The College does not discriminate on the basis of race, color, national origin, religion, marital status, gender, age or disability in admission or access to, or treatment or employment in its educational programs or activities. District grievance procedures will be followed for compliance with Title IX and Section 504 requirements. The Affirmative Action Compliance Officer is Director of Personnel, 103 First Avenue at Hopi Drive, Holbrook, AZ 86025, The Section 504 Compliance Officer is the Coordinator of Disability Resources and Access, 1001 W Deuce of Clubs, Show Low, AZ 85901, The lack of English language skills will not be a barrier to admission and participation in vocational education programs.

6 Nursing Programs POB 610 Holbrook, AZ (928) LICENSED PRACTICAL NURSE TO REGISTERED NURSE PROGRAM APPLICATION FOR ADMISSION Name Last First Middle Other names used now or in the past Address Mailing Address Number Street City State Zip Phone / Social Security Number Home Work/Message When do you anticipate starting the Nursing Program? Fall semester High school graduation date or GED date Have you completed the following prerequisite courses? (College courses over eight years old may be accepted with appropriate documentation. See Dean of Nursing.) You must fill in the following information. COURSE BIO 181 General Biology BIO 201 Human Anatomy & Physiology I BIO 202 Human Anatomy & Physiology II BIO 205 Microbiology CHM 130 Fundamental Chemistry ENL 101 College Composition I ENL 102 College Composition II NUR 117 Pharmacology I 4 cr 4 cr 4 cr 4 cr 4 cr 3 cr 3 cr 2 cr DATE COMPLETED OR SCHEDULED FOR COMPLETION SCHOOL/COLLEGE ATTENDED INSTRUCTOR GRADE Are you an AZ LPN? If so, License # Expiration Date Explain your career goals as an RN. (What do you want to do when you graduate from NPC?) Where would you prefer to attend classes? White Mountain Campus, Show Low Little Colorado Campus, Winslow Either Campus (Continued on reverse side)

7 LICENSED PRACTICAL NURSE TO REGISTERED NURSE PROGRAM APPLICATION FOR ADMISSION CONTINUED Bearing in mind the essential functions delineated in the Admission Information, are you able, with or without reasonable accommodations, to successfully perform these functions? Yes No Are you a legal resident of the United States of America? Yes No Have you ever been convicted of a felony? Yes No Are you currently using illegal drugs, misusing prescription drugs? Yes No Is there now or has there ever been regulatory action against any license you have held? Yes No Please yes, explain: (Regulatory action against any licenses you hold may be grounds for dismissal. Failure to report regulatory actions against your license may constitute a basis for dismissal Felony conviction, history of drug and/or alcohol addiction may be reason for denial of Registered Nurse License by the State Board of Nursing.) AFFIDAVIT STATE OF County of The undersigned being duly sworn declares that he/she is the person referred to in the foregoing application; that the statements are true in every respect; that he/she has not suppressed any information that would affect this application: that he/she will conform to the ethical standards of conduct in the profession of nursing; and that he/she has read and understands this affidavit. SIGNATURE SUBSCRIBED AND SWORN to before me this day of, 20 Commission Expires: Notary Public Notary Seal Return completed nursing application forms (before the deadline) to: Northland Pioneer College Nursing Programs P.O. Box 610 Holbrook, AZ Deadline is October 1. PUBLIC NOTICE OF NON-DISCRIMINATION: The College does not discriminate on the basis of race, color, national origin, religion, marital status, gender, age or disability in admission or access to, or treatment or employment in its educational programs or activities. District grievance procedures will be followed for compliance with Title IX and Section 504 requirements. The Affirmative Action Compliance Officer is Director of Personnel, 103 First Avenue at Hopi Drive, Holbrook, AZ 86025, The Section 504 Compliance Officer is the Coordinator of Disability Resources and Access, 1001 W Deuce of Clubs, Show Low, AZ 85901, The lack of English language skills will not be a barrier to admission and participation in vocational education programs. 7/07

8 NURSING PROGRAMS NOTICE OF NO GUARANTEE OF LICENSURE/CERTIFICATION Admission or graduation from the Program does not guarantee obtaining a license or certificate to practice nursing. Licensure and certification requirements and the subsequent procedures are the exclusive right and responsibility of the Arizona State Board of Nursing. Students must satisfy the requirements of the Nurse Practice Act: Statues, Rules, and Regulations independently of any college or school requirements for graduation as they exist at the time of licensure/certification. Although this explanation and handbook materials may provide information concerning the licensing process, the applicant/student is solely responsible for understanding and meeting licensure/certification requirements. NPC does not guarantee the accuracy of any of the information presented here or in any other materials presented to the applicant/student concerning the licensure process. Verifying the accuracy of such information is solely the responsibility of the applicant/student. If convicted of a felony, an applicant for licensure/certification must submit proof that he/she has received an absolute discharge from the sentences for all felony convictions five or more years prior to the date of filing an application" (Nursing Practice Act 2002, and ). Such proof includes completion of any sentence including imprisonment, probation, parole, community supervision or any form of court supervision. Examples of unprofessional conduct, but not limited to, are felony or misdemeanor convictions, substance abuse, conviction of an offense involving immoral behavior, or being guilty of acts which deceive, defraud or harm the public in any way. Fingerprinting will be part of the application process for the nursing assistant, LPN and RN applicants. If there is any question about eligibility for licensure or certification, contact the Arizona State Board of Nursing ( ). I have read and understood the above statement. Signature Date This statement will become part of your permanent record. PUBLIC NOTICE OF NON-DISCRIMINATION: The College does not discriminate on the basis of race, color, national origin, religion, marital status, gender, age or disability in admission or access to, or treatment or employment in its educational programs or activities. District grievance procedures will be followed for compliance with Title IX and Section 504 requirements. The Affirmative Action Compliance Officer is Director of Personnel, 103 First Avenue at Hopi Drive, Holbrook, AZ 86025, The Section 504 Compliance Officer is the Coordinator of Disability Resources and Access, 1001 W Deuce of Clubs, Show Low, AZ 85901, The lack of English language skills will not be a barrier to admission and participation in vocational education programs. 7/07

9 Nursing Programs POB 610 Holbrook, AZ (928) LICENSED PRACTICAL NURSE TO REGISTERED NURSE PROGRAM Professional or Academic Reference (Reference name) (Reference address) (Name of Applicant) Is applying for acceptance into the Associate Degree Nursing Program at Northland Pioneer College. Please fill out the following form. Your cooperation is greatly appreciated. When completed, please return to the Nursing Programs at the above address. In accordance with the Family Education Rights and Privacy Act, the applicant has requested has not requested that this information be held confidential by the Admission Committee. I hereby waive my right to inspect and review this letter of recommendation. I understand that (applicant) this waiver is not required as a condition of admission or receipt of a service or benefit from NPC. (signature of applicant). Attitude, motivation Above Below Comments: Initiative, creativity Interpersonal relationships Reaction to criticism Dependability, responsibility Maturity in judgment; handling of crises Personal habits; courtesy, grooming Additional comments: How long have you known this applicant? Relationship to applicant? Highly recommend Recommend Do not recommend Signature Occupation/position Date Thank you for completing this Personal Reference. Please return promptly (before October 1 deadline). PUBLIC NOTICE OF NON-DISCRIMINATION: The College does not discriminate on the basis of race, color, national origin, religion, marital status, gender, age or disability in admission or access to, or treatment or employment in its educational programs or activities. District grievance procedures will be followed for compliance with Title IX and Section 504 requirements. The Affirmative Action Compliance Officer is Director of Personnel, 103 First Avenue at Hopi Drive, Holbrook, AZ 86025, The Section 504 Compliance Officer is the Coordinator of Disability Resources and Access, 1001 W Deuce of Clubs, Show Low, AZ 85901, The lack of English language skills will not be a barrier to admission and participation in vocational education programs. 7/07

10 Nursing Programs POB 610 Holbrook, AZ (928) LICENSED PRACTICAL NURSE TO REGISTERED NURSE PROGRAM Professional or Academic Reference (Reference name) (Reference address) (Name of Applicant) Is applying for acceptance into the Associate Degree Nursing Program at Northland Pioneer College. Please fill out the following form. Your cooperation is greatly appreciated. When completed, please return to the Nursing Programs at the above address. In accordance with the Family Education Rights and Privacy Act, the applicant has requested has not requested that this information be held confidential by the Admission Committee. I hereby waive my right to inspect and review this letter of recommendation. I understand that (applicant) this waiver is not required as a condition of admission or receipt of a service or benefit from NPC. (signature of applicant). Attitude, motivation Above Below Comments: Initiative, creativity Interpersonal relationships Reaction to criticism Dependability, responsibility Maturity in judgment; handling of crises Personal habits; courtesy, grooming Additional comments: How long have you known this applicant? Relationship to applicant? Highly recommend Recommend Do not recommend Signature Occupation/position Date Thank you for completing this Personal Reference. Please return promptly (before October 1 deadline). PUBLIC NOTICE OF NON-DISCRIMINATION: The College does not discriminate on the basis of race, color, national origin, religion, marital status, gender, age or disability in admission or access to, or treatment or employment in its educational programs or activities. District grievance procedures will be followed for compliance with Title IX and Section 504 requirements. The Affirmative Action Compliance Officer is Director of Personnel, 103 First Avenue at Hopi Drive, Holbrook, AZ 86025, The Section 504 Compliance Officer is the Coordinator of Disability Resources and Access, 1001 W Deuce of Clubs, Show Low, AZ 85901, The lack of English language skills will not be a barrier to admission and participation in vocational education programs. 7/07

11 Nursing Programs POB 610 Holbrook, AZ (928) LICENSED PRACTICAL NURSE TO REGISTERED NURSE PROGRAM Professional or Academic Reference (Reference name) (Reference address) (Name of Applicant) Is applying for acceptance into the Associate Degree Nursing Program at Northland Pioneer College. Please fill out the following form. Your cooperation is greatly appreciated. When completed, please return to the Nursing Programs at the above address. In accordance with the Family Education Rights and Privacy Act, the applicant has requested has not requested that this information be held confidential by the Admission Committee. I hereby waive my right to inspect and review this letter of recommendation. I understand that (applicant) this waiver is not required as a condition of admission or receipt of a service or benefit from NPC. (signature of applicant). Attitude, motivation Above Below Comments: Initiative, creativity Interpersonal relationships Reaction to criticism Dependability, responsibility Maturity in judgment; handling of crises Personal habits; courtesy, grooming Additional comments: How long have you known this applicant? Relationship to applicant? Highly recommend Recommend Do not recommend Signature Occupation/position Date Thank you for completing this Personal Reference. Please return promptly (before October 1 deadline). PUBLIC NOTICE OF NON-DISCRIMINATION: The College does not discriminate on the basis of race, color, national origin, religion, marital status, gender, age or disability in admission or access to, or treatment or employment in its educational programs or activities. District grievance procedures will be followed for compliance with Title IX and Section 504 requirements. The Affirmative Action Compliance Officer is Director of Personnel, 103 First Avenue at Hopi Drive, Holbrook, AZ 86025, The Section 504 Compliance Officer is the Coordinator of Disability Resources and Access, 1001 W Deuce of Clubs, Show Low, AZ 85901, The lack of English language skills will not be a barrier to admission and participation in vocational education programs. 7/07