Application for Nursing Admission: A.S. Nursing or Practical Nursing Certificate Program

APPLICATION December, 2014 Application for Nursing Admission: A.S. Nursing or Practical Nursing Certificate Program Instructions, Policies, Procedures, and Schedule Information All documents must be received by the application deadline: Postmarked or received no later than February 1, by 4:30 p.m. 1. Review the admissions, academic, and prerequisite requirements for the A.S. Nursing Program or Practical Nursing Certificate Program. 2. Complete the entire application process (see below) and mail all documentation to: Holyoke Community College, Admissions Office, 303 Homestead Avenue, Holyoke, MA 01040 by Feb. 1, 2015. Required admissions documentation: The completed HCC Nursing/Practical Nursing application along with a $25.00 non-refundable application fee. Please make bank check or money order payable to Holyoke Community College. An official transcript from your high school or an official copy of GED/ HiSET scores or GED/HiSET certificate. All documents must be received directly from the high school or testing facility. Official transcripts for all college-level courses completed. You are required to submit any college transcripts prior to the Feb. 1 deadline. All Immunization Records and the HPAH record (pg. 14) must be submitted to HCC Health Services (Frost 105) by Feb. 1. The Work Experience Form, the Proficiency/Coursework Assessment Form, and the Laboratory Science Petition Form (if applicable) must be submitted at the time of application. Please note: Applicants who have submitted high school, GED, or college transcripts within the past year are not required to submit them again unless documenting further coursework completed toward the Nursing programs. Students whose native language is not English and those who have not completed grades K-12 in the United States must demonstrate English proficiency by having completed Language and Literature I with a grade of C+ or better, or a bachelor s degree from an accredited U.S. college or university or achieve a minimum of 213 on the computer version or 550 on the paper/pencil version of the Test of English as a Foreign Language (TOEFL). International applicants and those who have studied outside of the United States: All documents awarded (both secondary and post-secondary) from a country outside of the United States must be translated and evaluated to U.S. standards through a credential evaluating agency. Agencies can be found at www.naces.org. Post-secondary documentation need only be evaluated if seeking transfer credit to Holyoke Community College. 3. All students interested in the A.S. Nursing Program or Practical Nursing Certificate Program at Holyoke Community College are required to attend a mandatory Nursing Information Session prior to February 1, 2015 and no more than 1 year ago. Information sessions are held monthly and cover the selective admissions process, specific program information, and financial aid. Each session lasts approximately one hour and is conducted by a representative from the Nursing department. Check the website www.hcc.edu for upcoming information sessions. 4. Students who have not yet completed a math or English course from an accredited college or university are required to take the College Placement Test (CPT) at HCC prior to applying. The test provides a comprehensive academic assessment of students ability in reading, writing and math and is used to help place students into appropriate courses. Placement testing may be scheduled by calling the Assessment Center at (413) 552-2015. 5. All nursing applicants must take the NLN pre-entrance exam (PAX). PN and RN applicants have different pre-entrance exams. Students applying to both programs will need to register and complete both exams. PN Exemption: Practical Nursing Graduates of the HCC program that have graduated June 2012 or after are exempt from the PAX exam. However, these PN graduates are required to have attended a Nursing Information Session within one year of the application deadline, be licensed, and have one year of clinical practice in a health care setting prior to the start date of the third semester (of the ASN program). This 1+1 option is available for 3 consecutive application cycles from PN graduation date. 6. Notification of acceptance will be mailed on or before April 15, 2015. Requirements to Apply: All applicants must meet the following at time of application: A. Complete the PAX prior to submitting the PN or ASN application. PN and ASN applicants will complete different PAX. Students applying to both programs will need to register for and complete both exams. The NLN PAX composite average will be determined annually as part of the admissions criteria. The cost of each exam is $35.00. Registration is required three days prior to taking the exam, and registration must be completed online. To register for the PAX: Go to the NLN website: www.nlnonlinetesting.org Click registration store Click on Pre-Admission Exam (PAX) Payment: must be paid with a major credit card or money order. PAX testing takes place in the Assessment Center at HCC. For a complete listing of testing dates, go to www.nlnonlinetesting.org. (Prior to taking the PAX:) Copies of each PAX review guide are available in the HCC library. Review guides may be purchased at Barnes & Noble or Amazon.com. Because there are separate exams for the PN and RN PAX, each has its own review guide. 1 Nursing Programs Application/Instructions and Information

On the day of your PAX: 1. Please arrive at least 15 minutes prior to exam time and allow approximately 3 hours for testing. 2. A picture ID with signature identification, such as driver s license or passport is needed. 3. The PAX is administered at Holyoke Community College in the Assessment Center, Frost Building, room 271. The Assessment Center can be reached by calling (413) 552-2015. B. College Placement Testing (CPT): Must be completed within two years of application deadline demonstrating the following placement: Math Proficiency/Placement: 82 in Algebra or completion of MTH 095 (intermediate algebra) with a C- or better from an accredited college or university. English Proficiency/Placement: 70 in Reading and 80 in Sentence Skills of the CPT, or ability to enter college-level coursework in English. English competency may also be demonstrated through college coursework (completion of English Composition I). Please see the information packet for further details if English is not your first language or if you did not attend K through 12 in the U.S. Placement testing may be scheduled by calling the Assessment Center. NOTE: You must identify yourself as a NURSING APPLICANT when calling for your testing appointment in order to receive the appropriate test. Science Proficiency: The HCC Biology department requires the successful completion (C or better) of BIO 100, 103, or 107 prior to taking Anatomy and Physiology. This pre-requisite may be waived by passing the Biology Challenge Exam. Testing may be scheduled by calling the Assessment Center. Completion of A&P I and A&P II prior to the application deadline is strongly encouraged. Applicants currently working in a healthcare field can petition to lengthen the time that their laboratory science coursework is transferable to the Nursing program by completing the Laboratory Science Petition Form in this packet (see page 12). Nursing students must achieve a C+ or better in all nursing and laboratory science courses (A&P I and II and Microbiology) to graduate from the program. 2 Nursing Programs Application/Instructions and Information

Frequently Asked Questions If I will not meet the math requirement by deadline, will my file be reviewed? No, unfortunately your file will not go to the committee. Only those applicants who display the math requirement at time of deadline will be reviewed (see minimum requirements for consideration). I haven t completed the suggested coursework to apply to the A.S. Nursing Proggram or Practical Nursing Certificate program yet. Can I still come to HCC? YES! Students are encouraged to enter the college as a Foundations of Health student. In this major, you will be identified as a potential Nursing applicant and will be assigned to an advisor that will assist you in establishing an educational plan. As a student in this major, you may complete any of your non-nursing courses (e.g. A&P I and II, English I and II, Math 095, etc.) then apply to the program when you have met the requirements for consideration. Can I speak with an advisor about the A.S. Nursing Program or Practical Nursing Certificate program? Yes, you are required to attend a Nursing Information Session to meet with a representative from the programs. Check the website www.hcc.edu for upcoming information sessions. How is my file evaluated? The A.S. Nursing Program and the Practical Nursing Certificate program cohorts are selected from a pool of applicants who have displayed the minimum academic requirements for admission to the program. Space is limited and not all applicants are accepted. Applications will be reviewed and candidates will be notified of the admissions decision by mail on or about April 15. The process is competitive and your file will be ranked using the following: 1. Grade Point Average (GPA) for those courses applicable to the nursing curriculum (e.g. English, Psychology, Anatomy & Physiology, etc.). 2. Two or more years of work/volunteer experience in the field of healthcare. 3. Credits completed at HCC. 4. Educational background (prior degrees completed). 5. PAX results. If I am not accepted this year, will I automatically be accepted next year? No, you are not guaranteed acceptance. All applicants must reapply. Can I work and attend classes full time? Coursework is complex and requires a personal commitment. Parttime employment may be appropriate, but will need to be flexible in order to accommodate school requirements. Students are encouraged to balance their employment and school responsibilities. If I can t find my Immunization Records, what do I do? Ask your MD to perform antibody titer tests for the diseases, and submit a copy of the actual lab reports (not flow sheets) to Health Services by February 1. Can I take the PAX more than once? Prospective applicants will be allowed to take the NLN PAX once during each application cycle. Score is valid for two application cycles. Can I take the PAX at a different center? No. I was previously in a nursing program at a different institution. Can I apply to HCC? We do not take applicants who have been previously enrolled in a nursing program at a different institution in the past 10 years. Where do I attend a clinical setting or placement, and how do I get there? Nursing students are responsible for their own transportation to clinical sites which include healthcare agencies throughout the Pioneer Valley. Are recommendations accepted? Recommendations are not accepted. I am already an L.P.N. Is there a special program for me? Currently the A.S. Nursing Program does not offer a bridge program for LPNs. If I am not accepted into the A.S. Nursing Program, will my application automatically be considered for the Practical Nursing Certificate Program? No. If you would like your application considered for the Practical Nursing Certificate Program, you must check the appropriate box in the application, and take the PN PAX. Can I apply to a four-year school and earn a bachelor s degree? We encourage students to apply for admission to four-year accredited colleges and universities, including the Elms and AIC, among others. You may schedule an appointment with the Transfer Coordinator at (413) 552-2498 to discuss your specific goals. Can I apply for financial aid? Yes. Inquire at the Financial Aid Office, (413) 552-2150. We encourage all applicants to apply for financial aid. Additionally, what must I know? It is up to the applicant to read the essential functions standards and understand that it is his/her responsibility to discuss any accommodation that he/she may need by contacting the Office for Students with Disabilities and Deaf Services at (413) 552-2417. The applicant is responsible for ensuring that his/her application file is complete and that all items are received by the deadlines. No applications will be accepted after the February 1 deadline. The applicant must read the statement in the A.S. Nursing Program and Practical Nursing Certificate Program application regarding the CORI/ SORI policies. All Nursing students are required to complete a form. A positive finding may prevent a student from entering or successfully completing either program due to clinical site requirements and/or may prohibit them from taking the NCLEX-RN. In compliance with the Clery Act (20 U.S.C. 1092(a) and (f), all prospective students are entitled to review the HCC Annual Security Report. This report may be accessed online at www.hcc.edu or by request through the Office of Admissions. 3 Nursing Programs Application/Instructions and Information

Good Moral Character Clause CORI Policy Criminal Offender Record Information SORI Policy Sexual Offender Record Information CORI and SORI are state statutes that regulate licensure as a registered nurse. Prior to official enrollment and at the beginning of each semester in Nursing Programs, all accepted applicants and students must give permission for CORI and a SORI check. Some clinical agencies prohibit clinical participation if there is a finding when the CORI check is complete. Participation in planned clinical experiences throughout the curriculum is required; however, acceptance into the program does not guarantee placement in a clinical agency. All applicants and nursing students will be subject to the Criminal record Information Act (CORI check), the Sex Offender Registry Information Act (SORI), Massachusetts General Laws, Chapter 6, Section 172-178, and Massachusetts General Laws, Chapter 18a, Section 1, et. seq., and regulations promulgated pursuant to such statutes. Court record/past conviction may present a barrier to eligibility for licensure as a registered nurse (RN) or as a licensed practical nurse (LPN). Applicants with a court record/past conviction are advised to consult an attorney to determine eligibility to meet legal qualifications for nurse licensure in Massachusetts. All applicants for licensure as a registered nurse (RN) or a Practical Nurse (LPN) must be of good moral character as required by the Massachusetts Board of Registration in Nursing statutes and regulations. The licensure applicant must have had no criminal convictions for a minimum of five (5) years before the date of submission of the license application, and must have successfully completed all court-ordered stipulations a minimum of one (1) year before the applicant will be considered for licensure by the Board (Massachusetts General Laws, Chapter 112, ss. 74, 74A, and 76). You can also refer to http://www. state.ma.us/reg/boards/rn for further information. Students accepted to an educational program that prepares for licensure as a registered nurse should be aware that a court record may present a barrier to her/his ability to obtain licensure in the Commonwealth of Massachusetts and other jurisdictions in the United States. Special Program Requirements The following special program requirements MUST BE submitted to the Office of Health Services by February 1: Completed and passed physical examination and submit the Health Affiliate record signed, stamped, and dated by the MD in the calendar year of acceptance to the program by February 1. Documentation of completed vaccination series and, if necessary boosters, for the following must be given to the College Health Services office: Hepatitis B (3 shots); Measles, Mumps and Rubella (2 shots); Pertussis-containing vaccine (Tdap with trade name Adacel or Boostrix); Note: Tetanus Toxoid (TT) or Tetanus Diphtheria (Td) does not suffice; and Varicella (2 shots). Vaccines must be documented with month, day and year of administration and on MD office letterhead and/or stamped with facility address and phone number. (If antibody titers are done in lieu of vaccines, documentation required are the official copies (NOT MD flow sheets) of laboratory results. DO NOT GET TB TESTED NOW. A two step TB test and influenza vaccination will be required AFTER acceptance into the program. Information will be provided at orientation. Mandatory Health Insurance Coverage: All students must be covered by health insurance either through the college or through their family health plan. College Health Insurance will cover students for exposures and or injuries sustained in traveling to or from the college as well as attending any college-related activity including clinical experiences. Seasonal Influenza vaccine is mandated by various health facilities. These vaccines are administered every fall semester and will be due by September 15. It is the student s responsibility to keep these requirements current throughout the duration of the program. Students must notify Health Services if changes occur. Failure to keep requirements updated or not informing Health Services will result in the student s inability to attend clinical. This will result in an unsatisfactory grade for each clinical day missed. Two clinical unsatisfactory ratings in any course result in dismissal from the program. Please note these requirements may be subject to change per clinical agency request. Liability Insurance of $1,000,000/$3,000,000 coverage is required. Students will be covered under the college s liability insurance policy, which will be billed through student fees. Completion of CORI/SORI Form. (Out of state fees apply.) CPR certification through the American Heart Association only. (Professional Rescuer, Health Care Provider) is required. It is strongly suggested that all students take the CPR course by the program orientation date (generally in May), so certification will last the duration of the program. Students are required to travel off campus to reach clinical sites and no special consideration is given for clinical placements. Essential Functions The following essential functional abilities will be necessary to successfully enter and to remain in the Nursing programs. In some cases, assessment and developmental courses may help students meet these standards. These essential functional abilities may be performed with or without reasonable accommodation. This information is provided to allow the student to assess his/her own capabilities. The college complies with the requirements of Section 504 of the Rehabilitation Act and the Americans with Disabilities Act of 1990. The ADAAA was put into effect recently. Therefore, the college will make a reasonable accommodation for an applicant with a disability who is otherwise qualified. To ensure patient safety, students throughout the program must be able to demonstrate: 1. Physical Help in positioning patients who may be comatose, paralyzed, or otherwise incapacitated, from wheelchairs and beds, stretchers and vice versa. This includes regular lifting, bending twisting, pulling and pushing of 40+ pounds. Ability to use hands and arms in handling, installing, positioning, moving materials, and manipulating things. Frequently reaching above and below shoulder level, while holding objects. Position, place and move equipment as needed. Respond and monitor signals, alarms, and call lights. Fine and gross motor ability to sufficiently perform psychomotor skills. 2. Communicative Knowledge of the structure and content of the English language. Active listening - giving full attention to what others are saying, taking time to understand the points being made. Oral comprehension - the ability to listen and understand information and ideas presented through spoken words and sentences. Speech clarity - the ability to speak clearly so others can understand you. Speech recognition - the ability to identify and understand the speech of another person. Written expression - the ability to communicate information and ideas in writing so others will understand. 4 Nursing Programs Application/Instructions and Information

Communicating with others - providing information to other healthcare professionals by telephone, in written form, e-mail, or in person. Interacting with computers - using computers and computer systems including hardware and software. Civility in class/lab/clinical - polite, respectful, professional, behaviors exhibited. According to Holyoke Community College s Student Handbook, freedom to teach and freedom to learn are inseparable facets of academic freedom. The freedom to learn depends upon appropriate opportunities and conditions in the classroom, (lab and clinical area) on campus and in the larger community (Please refer to the HCC Student Handbook for complete policy). 3. Cognitive Clinical decision making - gather, analyze and draw conclusions from data. Control precision - demonstrate muscle dexterity necessary to do such tasks as gloving, gowning, performing physical assessment, performing psychomotor skills and operating controls on machinery. Problem sensitivity - the ability to tell when something is wrong or is likely to go wrong. Identify behaviors that would endanger a person s life or safety and intervene in a crisis situation appropriately. Tactile sensitivity - determine by touch: hotness/coldness, wetness/ dryness, and hardness/softness. 4. Emotional Dependability - requires being reliable, responsible, and dependable, and fulfilling role obligations. Integrity - requires being honest and ethical. Cooperation - requires being pleasant with others displaying a goodnatured, cooperative attitude. Self control - requires maintaining composure, keeping emotions in check, controlling anger and avoiding aggressive behavior even in very difficult situations. Concern for others - requires being sensitive to others needs and feelings. Initiative - requires a willingness to take on responsibilities and challenges. Stress tolerance - calmly and effectively participates in constructive dialogue in a variety of high stress situations. Adaptability/flexibility - requires the ability to manage unexpected events. United States Department of Labor in their Dictionary of Occupational Titles, Central Oregon Community College, Academic and Technical Standards. Drug Screening Policy Several Health Care Facilities affiliated with the College s Health and Natural Science Division are now requiring that students have a negative drug screen prior to beginning clinical experiences in their facility. In addition, a clinical facility may require the student to submit and pass random drug screening analysis in order to remain at that facility. Therefore, passing a drug screen will now be considered an Essential Function Standard for all students participating in the Health and Natural Science Division Programs. If a student fails drug screening, retesting occurs within 24 hours of notification of results. Failure to pass a drug screen or refusal to submit to screening will make the student ineligible for clinical placement. Failure and/or refusal for drug screening are grounds for immediate removal from the Health and Natural Science Division. Students will be provided with the drug screen procedure during the orientation process to each course. All screening will be at the student s own expense. The Work Connection at Holyoke Medical Center has been selected as the Health and Natural Science Division s exclusive laboratory for student drug screening. Accreditation The HCC Practical Nursing Certificate Program and the A.S. Nursing Program are approved by the Massachusetts Board of Registration in Nursing and the A.S. Nursing Program is accredited by the Accreditation Commission for Education in Nursing, Inc. (ACEN), 3343 Peachtree Road NE, Suite 850, Atlanta, Georgia 30326, (404) 975-5000, FAX (404) 975-5020, www.acenursing.org. 5 Nursing Programs Application/Instructions and Information

Practical Nursing Certificate - M064 Course Title Course Number Prerequisites Credits Semester Taken General Requirements 17 Grade Human Anatomy and Physiology I Human Anatomy and Physiology II BIO 217 A C grade or better in BIO 100 (including lab), BIO 103 or 107, or a passing grade on the challenge exam BIO 218 BIO 217 4 Nutrition NTR 101 Eligibility for ENG 101 3 Introduction to Psychology PSY 110 Eligibility for ENG 101 3 Human Development PSY 216 PSY 110 3 Fundamentals of Nursing NUR/PNR 170 Acceptance into the PN program Pharmacology I PHM 171 Acceptance into the PN program PNR 182 Role Development 1 NUR/PNR 172 Acceptance into the PN program Health Promotion and Maintenance Across the Life Span NUR/PNR 180 PNR 182, NTR 101 9 Pharmacology II PHM 181 Acceptance into the PN program PNR 182 Practical Nurse Role Development 2 Practical Nursing Acute & Complex Care Program Requirements 1 27 PNR 182 NUR/PNR 170, PHM 171, NUR/PNR 172 PNR 190 NUR/PNR 180, PHM 181 PNR 182 Total 44 4 9 1 2 1 2 3 Notes: 1 Nursing students must achieve a C+ or better in all Nursing and laboratory science courses (A&P I and II, and Microbiology) to graduate from the program. For additional information, go to www.hcc.edu 6 Nursing Programs Application/Instructions and Information

Nursing - M066 A.S. in Nursing Course Title Human Anatomy and Physiology II Human Anatomy and Physiology I Human Anatomy and Physiology II Course Number Prerequisites Credits Semester Taken BIO 218 BIO 217 4 General Requirements 30 BIO 217 A C grade or better in BIO 100 (including lab), BIO 103 or 107, or a passing grade on the challenge exam BIO 218 BIO 217 4 Microbiology BIO 229 Grade of C or better in BIO 100, 103 Language and Literature I Language and Literature II Introduction to Psychology Human Development Psychology ENG 101 Appropriate score on CPT, or C- or better in ENG 097 and ENG 098, or C- or better in ENG 096 or ENG 099 ENG 102 ENG 101 3 PSY 110 Eligibility for ENG 101 3 PSY 216 PSY 110 3 Nutrition NTR 101 Eligibility for ENG 101 3 Introduction to Sociology SOC 110 Eligibility for ENG 101 3 Program Requirements 1 42 4 4 3 Grade Fundamentals of Nursing (Fall) Health Promotion & Maintenance Across the Lifespan (Spring) Acute Care Across the Lifespan (Fall) Complex Care Across the Lifespan (Spring) NUR/PNR 170 Acceptance into the Nursing Program NUR/PNR 180 PNR/NUR 170, PNR/NUR 172 PHM 171 NUR 270 PNR/NUR 180, PNR/NUR 172 PHM 181 NUR 280 NUR 270, PHM 271 8 Pharmacology I PHM 171 Acceptance into the Nursing Program Pharmacology II PHM 181 PNR/NUR 170, PHM 171 1 Pharmacology III PHM 271 PNR/NUR 180, PHM 181 1 Pharmacology IV PHM 281 NUR 270, PHM 271 1 Role Development 1 (Fall) Role Development 2 (Spring) NUR/PNR 172 Acceptance into the Nursing Program NUR 282 NUR 270, PHM 271 2 Total 72 9 9 8 1 2 Notes: 1 Nursing students must achieve a C+ or better in all Nursing and laboratory science courses (A&P I and II, and Microbiology) to graduate from the program. For additional information, go to www.hcc.edu 7 Nursing Programs Application/Instructions and Information

REQUIRED STEPS PRIOR TO APPLYING ASN & PN Applicant Checklist Please submit with application. Mandatory Nursing Information Session attendance prior to February 1, 2015 & no more than 1 year ago. o Please indicate date attended $25.00 application fee (bank check or money order payable to Holyoke Community College) Computerized Placement Test (CPT) indicating proficiency in math & English or successful completion of college level course work in math and/or English NLN Entrance Exam (PAX) Requirements to Apply (page 1 for details). o Score(s) must be submitted at the time of application. o Applicants applying to both programs must take both entrance exams and submit scores for both. REQUIRED FORMS to SUBMIT Holyoke Community College fall 2015 Nursing Application Official High School or GED/HiSET transcript (copy of diploma or scores will not be accepted). Transcripts outside the United States must be translated and evaluated prior to submitting. Credential evaluating agencies can be found at www.naces.org Official college transcripts (if applicable). HCC transcripts will be generated by Admissions and do not need to be requested. Transcripts outside the United States must be translated, evaluated, and submitted with the application. Credential evaluating agencies can be found at www.naces.org Immunization forms and HPAHR form must be submitted to: Health Services, Frost Building, Room Frost 105 by February 1, 2015. Work Experience Form Proficiency/Coursework Assessment Form Laboratory Science Petition Form PAX results This checklist serves as a reminder of the applicant s responsibility prior to the February 1 deadline. All forms and steps listed above must be completed. Thank you! 8 Nursing Programs Application/Instructions and Information

APPLICATION Application for Nursing Admission: A.S. Nursing Program or Practical Nursing Certificate Program About You Social Security Number or HCC ID# (if known) Phone Number Cell Home Area Code Fall 2015 Application Deadline: February 1 Don t forget to return all required forms with your application. New, never attended HCC. A.S. Nursing readmit applicant - someone who has participated in HCC s A.S. Nursing program within the past two years. PN Nursing readmit applicant - someone who has participated in HCC s Practical Nursing Certificate program within the past two years. Current student /returning HCC student. LPN Grad from HCC after 2012. Previous Name (If applicable) December, 2014 Last Name First Name Middle Initial Home Address Birthdate (MM DD YYYY) City State Zip Code Male Female Mailing Address City State Zip Code Do you plan to enroll in English as a Second Language (ESL) program? Yes No Email: Person to contact in case of emergency: Last name First name Phone Have you previously applied to HCC s A.S. Nursing program or PN Nursing program? Yes No program or PN Nursing Program? Yes No LPN license with this application. Have you attended a Nursing Information Session? Yes No If no, please visit www.hcc.edu for dates and times. All applicants are required to attend a Nursing Information Session prior to applying. Attendance is taken at each session. Are you or have you ever been a member of the U.S. Armed Forces? Yes No If yes, please contact New Directions at (413) 552-2346. FAFSA Completion Holyoke Community College awards millions of dollars in federal, state and institutional financial aid each year to eligible students. Many students, however, miss out because they do not think they are eligible and do not complete the Free Application for Federal Student Aid (FAFSA). To apply for financial aid, students must complete the FAFSA available on the Federal Financial Aid website at www.fafsa. ed.gov. Financial Aid can be used to pay for tuition, fees, books, ipads, transportation, and other educational expenses. We strongly encourage you to complete the FAFSA. If you need help with your financial aid application or college financial planning, our Financial Aid Office has counselors who can assist you. Please select the option below that best describes your plans to complete a FAFSA. This information will have no impact on whether you are admitted to the college. I plan to apply for federal, state and institutional financial aid and am prepared to complete the FAFSA at www.fafsa.ed.gov. I plan to apply for federal, state and institutional financial aid, but I need help from the Financial Aid Office to complete the FAFSA. I do not plan to apply for federal, state or institutional financial aid at this time. Massachusetts Residency Statement Please check the in-state or reduced tuition eligibility category that applies to you: I have been a Massachusetts resident for six (6) continuous months and intend to remain here. As proof of my intent to remain in Massachusetts, I possess at least two of the following documents, which I shall present to the institution upon request. These documents* are dated within one (1) year of the start date of the academic semester for which I seek to enroll (except possibly for high school diploma). The institution reserves the right to make any additional inquiries regarding the applicant s status and to require submission of any additional documentation it deems necessary. Please check those documents you possess as proof of your intent to remain in Massachusetts. Valid driver s license Valid car registration Mass. high school diploma Utility bills* I am an eligible participant in the New England Board of Higher Education s Regional Student Program. Don t I am a member of the armed forces (or spouse or unemancipated child) on active duty in Massachusetts. Forget To Sign! Certification of Information I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall be cause for disciplinary action up to dismissal, with no right of appeal or to a tuition refund. Applicant signature: Record of parents residency for unemancipated person* Voter registration* Signed lease or rent receipt* Parent/guardian signature (applicant is under 18 years old): Date Date Employment pay stub* State/Federal tax returns* Military home of record* Other FOR OFFICIAL USE ONLY DO NOT WRITE IN THIS BOX Based on my review of the above information to determine this individual s eligibility to receive the in-state tuition rate, I have determined that: IS eligible for the in-state tuition rate. IS NOT eligible for the in-state tuition rate. I am unable to make a determination at this time. The following additional information has been requested from the applicant: Authorized college personnel If yes, when? Have you ever been accepted into HCC s A.S. Nursing If yes, which one? Are you currently a Licensed Practical Nurse? Yes No If yes, pleae submit a copy of your Please help us comply with state & federal reporting by indicating the ethnic group with which you identify. 1. What is your ethnicity? Hispanic or Latino Not Hispanic or Latino 2. Select one or more races to indicate what you consider yourself to be: American Indian or Alaskan Native Asian Black or African American Cape Verdean Native Hawaiian or Pacific Islander White I am applying for the Practical Nursing Certificate Program. I am applying for the A.S. Nursing Program. I am applying for both. 3. With which ethnic group do you identify? American Indian Black, Non-Hispanic Asian or Pacific Islander Hispanic White, Non-Hispanic Cape Verdean FOR OFFICIAL USE ONLY Application fee received by: Date: Check/M.O. # Date 9 Nursing Programs Application/Instructions and Information

Citizenship Status (Please select one) U.S. Citizen. If no, complete the following: Permanent Resident or Refugee (Resident Card or I-94 Required). Country of Birth: Country of Citizenship: If yes, list alien registration number: (Submit copy of alien registration to the Admissions Office) Non-Immigrant VISA (I-94 Required): Type: Country of Birth: Country of Citizenship: (International students see Admissions Office for an International Student Admissions Application and student VISA requirements) Education Please forward high school/home school/ged/hiset and college (if applicable) transcripts to the Office of Admissions. Graduation from secondary school or receipt of General Equivalency Diploma must be certified on the application form. High school seniors will certify after graduation. Do you have a high school diploma? Yes No Yes No Will you have graduated from high school or received your GED/HiSET PRIOR to starting classes at HCC? Date of high school graduation: Month /. / Year Expected date of high school graduation: Month /. / Year High school: City State If you graduated from a Massachusetts high school in 2003 or later, check one: I earned my high school diploma and satisfied MCAS requirements I earned my Massachusetts Certificate of Attainment I earned my high school diploma from a school that did not have MCAS requirements. Do you have a GED/HiSET (General Equivalency Diploma)? Yes Date of GED/HiSET completion: or Expected date of GED/HiSET completion: GED/HiSET testing location: City Month / Year Month / Year No Nursing Success Program Opportunity The goal of the Nursing Success Program is to diversify the student body of the A.S. Nursing Program in order to better reflect the local community. The Nursing Department, via the Nursing Resource Team, offers additional support services to Nursing Success students. These students will be randomly selected from the pool of applicants and must meet at least 1 of the following criteria: bilingual, economically disadvantaged, educationally disadvantaged, underrepresented minority. If interested in the Nursing Success Program please check-off the following criteria which you meet. The institution reserves the right to make any additional inquiries regarding the applicant s status and to require submission of any additional documentation it deems necessary. Bilingual Economically disadvantaged Educationally disadvantaged Underrepresented minority State Zip Other colleges or post-secondary schools attended: Name City/State Dates attended Degree(s) earned Name City/State Dates attended Degree(s) earned Name City/State Dates attended Degree(s) earned IMPORTANT! Student: I certify I have read and understand HCC s Nursing Application, Instructions, Policies, Procedures, and Schedule Requirements. Applicant: Signature Date: The HCC Practical Nursing Certificate Program and the A.S. Nursing Program are approved by the Massachusetts Board of Registration in Nursing and the A.S. Nursing Program is accredited by the Accreditation Commission for Education in Nursing, Inc. (ACEN), 3343 Peachtree Road, NE, Suite 850, Atlanta, Georgia 30326, (404) 975-5000, FAX (404) 975-5020, www.acenursing.org. Mail completed application with supporting documentation to: Holyoke Community College, Admissions Office, 303 Homestead Avenue, Holyoke, MA 01040. All documents must be received by the application deadline: Postmarked or received no later than February 1 by 4:30 p.m. 10 Nursing Programs Application/Instructions and Information

Application for Nursing Admission: A.S. Nursing or Practical Nursing Certificate Program Work Experience Form (Required. If form does not apply check here q ) Application Deadline: February 1 for September entrance. please print clearly HCC student ID number: SSN: Name of applicant: LAST FIRST MIDDLE INITIAL PREVIOUS NAME (IF APPLICABLE) Healthcare or related employment experience List employment with the most recent positions first. Attach additional sheets if necessary. (Resumes are acceptable. If submitting a resume be sure to add supervisor name and phone.) Please fill out information completely. Does not apply Employer Position Held Dates from/to (required) Supervisor name & phone (required) Must attach copies of all certifications held by applicant. Other certifications: List any current healthcare related certifications you hold (e.g., CNA, CPR, HHA, etc.) Does not apply I certify that all information stated on this application form is accurate and complete. Concealment of facts or false statement may result in dismissal. Applicant: Signature Date: Holyoke Community College seeks to provide equal educational and employment opportunities and does not discriminate on the basis of race, creed, color, religion, national origin, gender, age, sexual orientation, marital status, veteran status, or disability. 11 Nursing Programs Application/Instructions and Information

Application for Nursing Admission: A.S. Nursing Program or Practical Nursing Certificate Program Laboratory Science Petition Form (Required. If this form does not apply check here q ) Application Deadline: February 1 for September entrance. Office use only: Date Received: Laboratory Science Petition Form (a waiver may be granted for science courses taken more than seven years [and no more than fifteen years] for those currently employed in a healthcare field with direct patient contact). Notification of approval/denial will be mailed within 30 days of petition. HCC student ID number: SSN: Name of applicant: LAST FIRST MIDDLE INITIAL PREVIOUS NAME (IF APPLICABLE) Coursework: List course(s) you are seeking to petition to meet NUR or PNR course requirements. Does not apply Course Semester/year taken Grade received College/University Microbiology Anatomy and Physiology I Anatomy and Physiology II Employment experience related to the course(s) being petitioned: (Please describe how and in what capacity you use the curriculum from the courses listed above in your current employment). Please attach a separate sheet if more space is needed. Other certifications: List any current healthcare related certifications you hold (e.g. CNA, CPR, HHA, etc.) Does not apply I certify that all information stated on this application form is accurate and complete. Concealment of facts or false statement may result in dismissal. Applicant Signature Date Division of Health and Natural Sciences Signature Date Holyoke Community College seeks to provide equal educational and employment opportunities and does not discriminate on the basis of race, creed, color, religion, national origin, gender, age, sexual orientation, marital status, veteran status, or disability. 12 Nursing Programs Application/Instructions and Information

Nursing Programs Proficiency/Coursework Assessment Form Applicant must complete form. Please note: Official transcripts are required in order to receive credit. Coursework in progress will not be counted. How have you met the English and Math Proficiency Requirement? Note: If you have not met the proficiency requirements, your application will not be considered for review. English Proficiency Grade Where Completed or HCC CPT score Date Completed Intermediate Algebra (MTH 095) Coursework Completed Not needed for review, but applicants are strongly encouraged to complete prior to beginning program. Course Grade Where Completed Date Completed BIO 217 BIO 218 BIO 229 ENG 101 ENG 102 NTR 101 PSY 110 PSY 216 SOC 110 Anatomy & Physiology I Anatomy & Phsyiology II Microbiology Language and Literature I Language and Literature II Nutrition Introduction to Psychology Human Development Introduction to Sociology CRIMINAL OFFENSE RECORD INFORMATION ACT (CORI) AND SEX OFFENDER REGISTRY INFORMATION (SORI) STATE STATUTES THAT REGULATE LICENSURE AS A REGISTERED NURSE OR LICENSED PRACTICAL NURSE. CORI and SORI are state statutes that regulate licensure as a registered nurse or licensed practical nurse. Prior to official enrollment and at the beginning of each semester in Nursing Programs, all accepted applicants and students must give permission for CORI and a SORI check. Some clinical agencies prohibit clinical participation if there is a finding when the CORI check is complete. Participation in planned clinical experiences throughout the curriculum is required; however, acceptance into the program does not guarantee placement in a clinical agency. All applicants and nursing students will be subject to the Criminal Record Information Act (CORI check), the Sex Offender Registry Information Act (SORI), Massachusetts General Laws, Chapter 6, Section 172-178, and Massachusetts General Laws, Chapter 18a, Section 1, et seq., and regulations promulgated pursuant to such statutes. Court record/past conviction may present a barrier to eligibility for licensure as a registered nurse (RN) or as a licensed practical nurse (LPN). Applicants with a court record/past conviction are advised to consult an attorney to determine eligibility to meet legal qualifications for nurse licensure in Massachusetts. All applicants for licensure as RN or LPN must be of good moral character as required by the Massachusetts Board of Registration in Nursing statutes and regulations. The licensure applicant must have had no criminal convictions for a minimum of five (5) years before the date of submission of the license application and must have successfully completed all court ordered stipulations a minimum of one (1) year before the applicant will be considered for licensure by the Board (Massachusetts General Laws 112, ss.74, 74A, and 76). Refer to http://www.state.ma.us/boards/rn/ for further information. 303 Homestead Avenue Holyoke, MA 01040 Telephone: (413) 552-2321 www.hcc.edu 13 Nursing Programs Application/Instructions and Information

DO NOT SUBMIT FORM WITH APPLICATION! BRING TO HCC HEALTH SERVICES BY FEBRUARY 1. PHYSICAL EXAMINATIONS MUST BE PERFORMED AFTER JANUARY 1. Health Program (circle one) ASN PN RDL Student ID# HCC Health Program Affiliate Health Record HCC Health Services. Please contact us if you need additional information at (413) 552-2511. Section I: Identifying Information - Please print legibly Name (last) (first) MI Address Phone # ( ) DOB: email Section II: Significant Medical History - to be completed by clinician (include diagnoses of physical and/or emotional problems, impairments or restrictions, medications taken, allergies, drug sensitivities, etc.) Physical exam done by a licensed clinician (MD, NP, PA): HEENT Pulmonary Musculoskeletal Date of physical exam: Pulses Neck GI Lymphatic Neuro Cardiac GU Skin By signing on the line below the clinician states that this student is safe and capable of performing academic and clinical functions. Clinician Signature Printed Name Address Phone Date Section III: Immunization Records - Required: Attach Copies of: Immunization Records Lab Titer Reports (not flow sheets) X-ray Reports Health Requirements: 1. Complete and pass a physical examination and submit the Health Affiliate record signed, stamped, and dated by the MD in the calendar year of acceptance to the program by February 1. 2. Documentation of completed vaccination series and, if necessary boosters, for the following must be given to the College Health Services office: Hepatitis B (3 shots); Measles, Mumps and Rubella (2 shots); Pertussis-containing vaccine (Tdap with trade name Adacel or Boostrix); Note: Tetanus Toxoid (TT) or Tetanus Diphtheria (Td) does not suffice; and Varicella (2 shots). Vaccines must be documented with month, day and year of administration and on MD office letterhead and/or stamped with facility address and phone number. (If antibody titers are done in lieu of vaccines, documentation required are the official copies (NOT MD flow sheets) of laboratory results by February 1. 3. DO NOT GET TB TESTED NOW. A two step TB test and influenza vaccination will be required AFTER acceptance into the program. Information will be provided at orientation. Copies of any available immunization records must be turned into HCC Health Services (Frost 105D) by the application deadline, February 1. 4. Mandatory Health Insurance Coverage: All students must be covered by health insurance either through the college or through their family health plan. The College Health Insurance will cover students for exposures and or injuries sustained in traveling to or from the college as well as attending any college-related activity including clinical experiences. 5. Seasonal Flu vaccine is required by all clinical facilities. These vaccines are administered every fall semester, and are due by September 15. 6. It is the student s responsibility to keep these requirements current throughout the duration of the program. Students must notify Health Services if changes occur. Failure to keep requirements updated or not informing Health Services will result in the student s inability to attend clinical. This will result in an unsatisfactory for each clinical day missed. Two clinical unsatisfactory ratings in any course result in dismissal from the program. 7. Please note these requirements may be subject to change per clinical agency request. Students who fail to submit legible or complete forms, required lab titer or x-ray reports, or the Health Program Affiliate Health Record by deadlines, will be ineligible for acceptance in the health program. THIS BOX MUST CONTAIN STAMP OF FACILITY/PRACTITIONER WHO COMPLETES FORM: HCC Health Services, 303 Homestead Avenue, Holyoke, MA 01040 Phone: (413) 552-2511 Fax: (413) 552-2121 14 Nursing Programs Application/Instructions and Information December, 2014