Certificate Program Practical Nursing Application Spring 2016

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1 Moving Mountains Transforming Lives Practical Nursing Application Spring Open date: Wednesday, July 1, 2015 Applicants can begin submitting program applications. Close date: Tuesday, December 22, 2015 All required documentation listed on the application checklist must be received by the Admissions, Registration and Records office no later than 5 p.m. No postmark date allowed. No exceptions. Please print and complete the application pages to follow. Submit all application materials to: Mt. Hood Community College Admissions, Registration and Records Practical Nursing Application SE Stark St., Gresham OR 97030

2 APPLICATION PACKET CHECKLIST Every item on this checklist needs to be submitted by the application deadline December 22, Only completed applications containing all the required documents will be considered for review. You will not be given notification if items are missing. It is the responsibility of the applicant to make sure everything is received by the deadline. The following items must be submitted as part of a completed application: 1. Online General Admissions Form ( list general studies as your major. It will change to Practical Nursing if/when you are admitted into the program. 2. Application Checklist Page 2 3. Health Professions Division Application Page 3 4. Prerequisite Course Planning Sheet Page 4 5. Signed Practical Nursing Statement of Understanding Page 5 In addition to the documents above, applicants must also submit the following: 1. Current CNA Certification (Downloadable from your State Board of Nursing) OR Official Military Corpsman/Medic Documents (students must keep an active CNA through the whole program. 2. $50 Application Fee Make check payable to MHCC. Bank card/cash is only payable in person in Student Services (Room AC2253). 3. Official (in a sealed envelope) College Transcript(s) from EVERY COLLEGE EVER ATTENDED (do not include an MHCC transcript). Transcripts must document completion of the required coursework. By signing below I acknowledge/agree to the following: 1. MHCC s Admissions, Registration and Records office will send all application notification by . It is my responsibility to set my spam filter system to accept addresses Do this even if you are currently receiving s from MHCC. We cannot be responsible for notices which are not received due to spam or junk mail handling. Make sure to to your safe senders list. Applicants should be checking their on a computer and NOT on a smart phone. 2. I understand it is my responsibility to ensure all items are received by the application deadline and that only complete applications will be evaluated for admission. Furthermore, I have read and understand the admission requirements and procedures for admissions. I understand that withholding information or giving untruthful answers to questions on this application could be cause for non-acceptance or dismissal from the program. 3. I confirm each item on the checklist is included with my application or I have confirmed they are already on file at MHCC. I understand it is my sole responsibility to submit the required documents, and I will not be given notice if my application is incomplete until after the deadline, at which time it will be too late to submit missing documents. Printed Name: MHCC Student ID#: Signature: Date: / / Page 2 of 5

3 HEALTH PROFESSIONS DIVISION APPLICATION Name: SSN or MHCC ID: Previous last name(s): Current mailing address: ALL notifications will go out via to this address Phone number and alternate phone: Education Record: List ALL colleges attended (including MHCC). Omission of any college transcript may result in nonadmittance or dismissal from the program. ALL transcripts must be submitted regardless of age, program relevancy, or length of study (you do not need to submit MHCC transcripts). College: Did you earn a degree? Are current transcripts on file or have they been ordered? Previous Applications: List all medical programs you have previously applied to. Program Title: Application year(s): College: Were you accepted?* *Applicants who had been previous admitted, started, but did not finish a medical program must obtain a letter from the head of the department indicating the year(s) you attended, that you exited the program in good standing, and can speak to your ability to be successful in another medical program. Applicants who were dismissed from programs may not be eligible to apply. For Office Use Only Date Received: Received By: Page 3 of 5

4 PREREQUISITE COURSE PLANNING SHEET Applicant Name MHCC ID# For point assessment, only courses completed by the end of Fall term 2015 with a C grade or higher will be used. Science courses must have been completed within the last 7 years (not completed prior to Winter 2009). Fill out each section in its entirety. No points will be awarded if the course is not fully documented below. List the courses as they appear on your transcript. Do not use the MHCC equivalency or convert to quarter credits. If the course is currently in progress, put IP in the term/year box. Submit updated transcripts documenting your grade once the course is completed (not MHCC transcripts). Do not list courses you are planning to take Winter or Spring term. LLPN Prerequisites Course Term/Year Grade/Credit Institution EXAMPLE BI121 WI/11 A / 4 MHCC Required Coursework Must be completed by the application deadline December 22, 2015 BI121 OR BI231 AND BI232* -- Anatomy & Physiology I and Anatomy & Physiology ll Not completed prior to Winter MTH065 - Beginning Algebra (or higher) not completed prior to Winter 2010 or CPT placement into MTH095 WR121 English Composition CIS120L Computer Concepts RD117 Critical Reading Supporting Coursework Must be completed by the end of Winter term BI122 Anatomy & Physiology II OR BI233* - Anatomy & Physiology III Not completed prior to Winter PSY201** General Psychology Not required if you have already completed PSY237. Practical Nursing Program Coursework Can be completed prior to starting the program or during the specified term within the program PSY237 Human Development AH110 (OR MO114 AND MO115)- Medical Language for Healthcare Settings/Medical Terminology *If the applicant enrolls in a 3-term sequence course, the first 2 terms (BI231 and BI232) must be completed by the application deadline. By the start of this program, Spring term, the entire sequence must be completed. Page 4 of 5

5 PRACTICAL NURSING STATEMENT OF UNDERSTANDING Applicant Name MHCC ID# Please indicate that you have read and agree to each paragraph by checking each line. I have read and understand the admission criteria for the Practical Nursing (LPN) program at Mt. Hood Community College. I understand it is my responsibility to meet all program and application criteria. I verify that all statements on this application are complete and true, and I understand that falsification of any information may lead to disqualification or dismissal from the program. I understand I must have at least a 2.0 GPA in all of the required, supporting, and in program coursework. I understand if accepted to the LPN program, I am required to complete: BI122 or BI233 (completion of anatomy and physiology series) and PSY201 (if I have not already completed PSY237) with a C grade or better while still meeting the 2.0 GPA requirement by the end of Winter. I understand if I am accepted into the program, I will be expected to demonstrate the MHCC LPN program academic and essential functions with or without reasonable accommodations based on disability and approval from the Disability Services Office. I understand that clinical facilities may require a criminal history check be completed while the student is enrolled in the LPN program. I understand that if I am accepted into the program, for the purposes of public safety and health, if I have or develop any type of psychological, medical, drug or alcohol problem that impairs my ability to provide safe client care, or if I have an arrest or conviction history that would disqualify me from patient care in a clinical facility or licensure by the Oregon State Board of Nursing (OSBN), the LPN faculty/selection committee may consult with legal counsel and/or the OSBN and reject or dismiss me from the program. Upon application for licensure, applicants will be subject to a criminal background check performed by the Oregon State Board of Nursing (OSBN). Certain crimes may disqualify an applicant from licensure. Any individual who supplies false or incomplete information to the Board regarding the individual's criminal conviction record will be denied licensure. Specific questions regarding these issues should be directed to the OSBN at SW Upper Boones Ferry Road, Portland, OR 97224, (971) , or oregon.gov/osbn. I understand the college uses a management learning system called Blackboard which is an integral part of all LPN courses and that accepted students must have access to a computer with software that includes Microsoft Word 2007 and Power Point. Internet access will be required on a daily basis. I understand that a mandatory orientation will be held for admitted and alternate students on Thursday, March 3,, 10:00 am 5:00 pm, no exceptions. My attendance at the mandatory orientation is required, and I will attend this mandatory orientation or the next eligible alternate will be given my assigned place in the program. I understand that, as an accepted student I will submit my required immunizations, CPR card, and all other required documents by March 8,. If I am an alternate student, I will have these documents ready to submit by this date should a position become available. I understand that, as an accepted or alternate student, I must provide a current Healthcare Provider CPR card approved by the American Heart Association. This program will accept only Healthcare Provider CPR cards from the American Heart Association, and I will obtain the appropriate card type. The CPR course must have been completed (and submitted) by March 8, (no exceptions) and must be valid for the duration of the program. I understand that if I have applied to the LPN or other restricted entry health profession programs at MHCC in the same admission year, and I accept a position in the LPN program, my application to other restricted entry health profession programs will not be considered for that year. Page 5 of 5

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