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T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
ASSOCIATE DEGREE NURSING PROGRAM
Student Application
Application Period: November 1, 2019- January 31,2020
Select which Program you are applying for? ____ ADN Program ____ LVN- ADN Bridge
1. Have you ever enrolled an RN program? If yes, when and where___________________________ *if yes, complete page two of the application 2. Obtained LVN licensure via BVNPT method 4 challenge Yes____ *if yes please provide military transcripts
Name: _________________________________________________________________________________________________ Last First Middle Social Security Number Address: ___________________________________________________ Birthday: MM/DD/YYYY_________________ City/State/Zip: _________________________________Primary phone______________ Message phone__________________ Alias(es)/Other Names: _____________________________ E-Mail: _______________________________________________
EDUCATION
HIGH SCHOOL: Please check only one item and submit supporting documentation (i.e., unofficial high school transcript, or copy of diploma, or GED/CHSPE,) __ Have a high school diploma. Name of HS and Year Graduated ______________________________________________ __ Earned a G.E.D. with a minimum score of 45(required) __ Foreign Secondary School Diploma/Certificate of Graduation
__Received a California High School Proficiency Certificate (CHSPE)
Note: See West Hills College Lemoore Catalog, WHCL Counselor, WHCL Website, RN Student Handbook and the Board of Registered Nursing Website (www.rn.ca.gov) for appropriate classes and other nursing requirements.
Signature______________________________________ WHCL ID#__________________ Date_______________________
COLLEGES: List all colleges previously attended or currently enrolled, EVEN West Hills College. Failure to disclose ALL colleges and submit official transcripts is considered academic fraud and students will be subject to immediate dismissal.
College Name City State Dates Attended ___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Please use reverse side for additional information
Official
Transcripts Rec’d
_______
I HEREBY CERTIFY, under penalty of perjury, that all information supplied on this document is complete and accurate to the best of my knowledge. I further understand that any misinformation, intentional or otherwise, WILL result in my removal of consideration for selection. I also acknowledge that I have fully read and understand the Student Application Information Sheet.
Date Received:
One (1) OFFICIAL, SEALED COLLEGE TRANSCRIPTS (FOR EVERY COLLEGE ATTENDED) one unofficial WHC, AND ONE UNOFFICIAL HIGH SCHOOL TRANSCRIPT/DIPLOMA OR GED/CHSPE TRANSCRIPT MUST BE SUBMITTED WITH YOUR APPLICATION PACKET.
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
West Hills College Lemoore Health Careers 555 College Ave Lemoore, California 93245 www.westhillscollege.com
Have you enrolled more than one RN program? Yes____ No____ *Please provide a letter or recommendation to attend our program on College letterhead from the Director of the Nursing program from which you once attended. You may attach the letter to this application
Applicant Name: _____________________________________________________________________ Last First Middle Name of Nursing Program last attended______________________________________________________________________ Address/City/State/Zip: __________________________________________________Primary phone______________________ Program Director’s Name: _____________________________ E-Mail: _______________________________________________
Nursing Program Attendance Date entered Program______________ Date left Program_____________ Did you repeat any nursing courses in the program? Yes___ No____ If yes, which courses did you repeat?______________________________________________________________________ ____________________________________________________________________________________________________ Were you offered to continue with the program? Yes___ No___
Note: See West Hills College Lemoore Catalog, WHCL Counselor, WHCL Website, RN Student Handbook and the Board of Registered Nursing Website (www.rn.ca.gov) for appropriate classes and other nursing requirements. All immunizations, physical, liability and health professional CPR requirements, consents, proof of valid transportation, background check, etc. must be met prior to final admission to the program.
Signature______________________________________ WHCL ID#_____________ Date_______________________
Please provide a brief description of why you did not remain in the program and what you can bring to the West Hills College Lemoore Nursing Program as an enrolled student. You may attach a separate document to this application if the space below is not sufficient.
I HEREBY CERTIFY, under penalty of perjury, that all information supplied on this document is complete and accurate to the best of my knowledge. I further understand that any misinformation, intentional or otherwise, WILL result in my removal of consideration for selection. I also acknowledge that I have fully read and understand the Student Application Information Sheet.
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
WEST HILLS COLLEGE LEMOORE Application Period: November 1,2019 to January 31, 2020
Assoc. Degree of Nursing LVN-RN Program Nurse Assistant Medical Assistant Paramedic Program
Student Demographics Sheet
Name: ___________________________________________
Social Security # WHCL ID#___________________
Primary Language: Additional Languages:__________________
Birth date:
Date Entered Program: Date Expect to Graduate:
1. Age: (a) 18-25 (b) 26-35 (c) 36-45 (d) 46-55 (e) >56 (f) Info not available
2. Ethnic Background: (a) Native American (b) Asian or Pacific Islander
(c) African American (d) Filipino (e) Hispanic (ab) White, non Hispanic (ac) Other
(ad) Unknown
3. ESL (English as a Second Language)? Yes No
4. Gender: Male Female __ Nonbinary _______
5. Do you receive financial aid? Yes (a) No (b)
Type (BOGG waiver, Workforce, etc.)_________________________________________
6. Are you currently employed? _____ Yes _______ No Where? ___________________
FOR OFFICE USE ONLY
TEAS VERSION:____ Date Taken:______________ Adj. Score:__________%
Rdg________% Math________% Science________% English________%
Prerequisite GPA:__________
Cumulative GPA:__________
Total Points:__________
Start Date:__________ Cohort: Class of___________
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
Application Period: November 1,2019 to January 31, 2020
West Hills College Lemoore
Health Careers
RELEASE OF INFORMATION Personally identifiable information from educational records cannot be released without the prior written
consent of the student, except as specified under the provisions of FERPA (Family Educational Rights and
Privacy Act of 1974).
The West Hills College Lemoore Health Careers Office is required by its contracts with various health facilities
for clinical placements with clinical and community institutions to provide certain personal information to the
agency. The release of information is required in order to allow you to receive your clinical experience. The
clinical agencies are required to have certain information because of JACHO accreditation and other Federal
requirements.
It is therefore necessary for you to provide your clinical instructor a Release of Information form when you
give her/him the immunizations, TB test results, malpractice insurance information, etc. as requested by each
clinical agency.
By signing this form you are giving the school and WHCL Health Careers or its representative such as your
clinical instructor, the right to provide your personal and academic information to the agency in need of specific
information necessary for your clinical rotation. This includes the release of your grades on a pass/fail basis and
for any safety issues that might arise.
Name of Student:
Please print your name
Name of Student:
Please sign legibly
Date:
West Hills College
Student ID Number:
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
ASSOCIATE DEGREE REGISTERED NURSING PROGRAM
Work or Volunteer Experience in Healthcare Verification
Applicant Instructions: write legibly (illegible forms will not be accepted) 1. Complete sections A and B. 2. Ask your employer/volunteer coordinator to complete section C and return this form and their cover letter to you on company letterhead. Make sure they list the position you hold at the agency. 3. Make a copy of the front and back of your active license or certification and staple copy to this form. 4. Submit this form, copy of license/certification, and employer letter with your application.
A. Applicant Information Name: first middle last
Address: number & Street city State zip code
Contact Information: primary phone number secondary phone number my.whccd.edu email address ( ) ( ) @my.whccd.edu
B. Employer or Volunteer Facility Information Employer/Volunteer Facility Name:
Type of Health Care Facility:
Name & Title of Supervisor: Address: number & Street city State zip code
Contact Information: primary phone number secondary phone number email address ( ) ( )
C. Employer or Volunteer Coordinator- Please Complete This Section: Position held by applicant:
Dates of Employment: Start Date: End Date: ( ) Full Time ( ) Part Time ( ) Paid Work ( ) Volunteer Work
( ) Please attach a cover letter on agency letterhead describing the applicant’s work and/or volunteer experience. Return this form and letter to applicant so they can submit with their application. Letter must include the applicant’s name, start date and end date, employment status (full-time/part-time/volunteer), number of hours worked per month, and approximate total of hours worked. Include job title, department, and example of duties (including patient interaction)
____________________________________________________________________________________ Name and title of person completing Section C Signature Date
Total number of hours worked per month
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
Certification of Language Proficiency
•To be submitted with the Registered Nursing Application•
Instructions: Please complete the following form to meet the criteria for Native Speaker ____________________________________________________________________________________________________
•To be completed by student• Name: _____________________________________ Phone:_________________________________________ Student Certification of Proficiency Language other than English: ________________________________________ English is: First Language Second Language
______________________________________________________________________________________________________ •To be completed by Professor, Clergy Member, or Supervisor•
(NOT A CLOSE FRIEND/RELATIVE)
Name: ____________________________________________ Title: _________________________________________ Organization:___________________________________________________________________________________________ Address: __________________________________________ City/State/Zip: ________________________________________ Phone: _________________________________________ Email: _______________________________________________ •How long have you known the student and in what capacity? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
•How often have you observed the student conversing/translating in this language?
Daily 3+ days per week 1= days per week
•Please rate the student on a scale from 1 (low) to 3 (high) • Student’s proficiency in speaking this language: 0 1 2 3 Student’s proficiency in writing this language: 0 1 2 3 Student’s proficiency in reading this language: 0 1 2 3 ______________________________________________________________________________________________________ I certify that I am fluent in the identified foreign language as listed above and that I have observed the listed student and his/her language skills within the past year. Signature: __________________________________________________ Date: ____________________________________
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
Life Experiences or special circumstances of an applicant
For documentation for this category of the Life Experiences or Special Circumstances
Disabilities
Attach this cover sheet to your documentation specific to Disabilities
Documentation required:
Proof of eligibility for Disabled Student Programs and Services (DSPS).
Students Name________________________________ WHCL ID #_________________
If this cover sheet is not attached to the documentation you are submitting it may not be accepted.
This cover sheet will ensure your documentation is easily identified in the application review.
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
Life Experiences or special circumstances of an applicant
Veteran
For documentation for this category of the Life Experiences or Special Circumstances
Attach this cover sheet to your documentation specific to Veteran
Documentation required:
- Copy of form DD214
Students Name____________________________ WHCL ID #_________________
If this cover sheet is not attached to the documentation you are submitting it may not be accepted.
This cover sheet will ensure your documentation is easily identified in the application review.
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
Life Experiences or special circumstances of an applicant
Refugee
For documentation for this category of the Life Experiences or Special Circumstances
Attach this cover sheet to your documentation specific to Refugee
Documentation required:
- Documentation or letter from USCIS
Students Name_________________________________ WHCL ID #_________________
If this cover sheet is not attached to the documentation you are submitting it may not be accepted.
This cover sheet will ensure your documentation is easily identified in the application review.
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
Life Experiences or special circumstances of an applicant
Need to Work
For documentation for this category of the Life Experiences or Special Circumstances
Attach this cover sheet to your documentation specific to Need to Work
Documentation required:
Paycheck stub from the period of time you were enrolled in RN prerequisite courses, or a letter
from employer (must be on organization letterhead) verifying employment was at least part-time
while completing courses
Students Name___________________________________ WHCL ID #_________________
If this cover sheet is not attached to the documentation you are submitting it may not be accepted.
This cover sheet will ensure your documentation is easily identified in the application review.
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
Life Experiences or special circumstances of an applicant
Low Family Income
For documentation for this category of the Life Experiences or Special Circumstances
Attach this cover sheet to your documentation specific to Low Family Income
Documentation required:
Proof of eligibility or receipt of financial aid under a program that may include but is not limited to:
a fee waiver from the Board of Governors, Cal Grant Program, Federal Pell Grant program; or Cal
Works
Students Name_____________________________________ WHCL ID #_________________
If this cover sheet is not attached to the documentation you are submitting it may not be accepted.
This cover sheet will ensure your documentation is easily identified in the application review.
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Life Experiences or special circumstances of an applicant
First Generation of Family to Attend College
For documentation for this category of the Life Experiences or Special Circumstances
Attach this cover sheet to your documentation specific to First Generation of Family to Attend
College
Documentation required:
Personal written (typed) statement-provide brief description on explaining situation or
circumstances
Students Name_____________________________________ WHCL ID #_________________
If this cover sheet is not attached to the documentation you are submitting it may not be accepted.
This cover sheet will ensure your documentation is easily identified in the application review.
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
Life Experiences or special circumstances of an applicant
Disadvantages social or educational environment
For documentation for this category of the Life Experiences or Special Circumstances
Attach this cover sheet to your documentation specific to Disadvantages social or educational
environment
Documentation required:
Proof of participation or eligibility for Extended Opportunity Programs and Services (EOPS),
Upward Bound Program, or other
Students Name____________________________________ WHCL ID #_________________
If this cover sheet is not attached to the documentation you are submitting it may not be accepted.
This cover sheet will ensure your documentation is easily identified in the application review.
T:\Health Careers\LEMOORE\RN-Lemoore\RN\ADN Application forms 10/15/18
Life Experiences or special circumstances of an applicant
Difficult personal and family situations or circumstances
For documentation for this category of the Life Experiences or Special Circumstances
Attach this cover sheet to your documentation specific to difficult personal and family situations
or circumstances
Documentation required:
Personal written statement- provide brief description on explaining situation or circumstances
Students Name__________________________________ WHCL ID #_________________
If this cover sheet is not attached to the documentation you are submitting it may not be accepted.
This cover sheet will ensure your documentation is easily identified in the application review.