Attatch current
photo no larger than
2X2 with name
written on back
Department of Nursing Education
APPLICATION FOR
ASSOCIATE DEGREE NURSING
Print Name:
SS# or PRCC Student ID#:
Home Number:
Cell Number:
Emergency Contact Number:
________________________________________________________________________________________________
I am applying for:
☐ FALL
☐ SPRING
Year:
_________________________________________________________________________________________________
I.
INSTRUCTIONS
A.Complete this application and place it in the Application Drop Box in the Nursing Building Lobby Area
B.
II.
Submit an unofficial copy of your High School and/or all College(s) transcripts to the Department of
Nursing Education, Admissions Office.
PERSONAL DATA
Name: First:
Middle/Maiden:
Last:
Street Address:
PO Box:
County:
City:
State:
Zip Code:
Email Address:
Date of Birth:
Age:
Sex:
Ethnic Origin:
1
Marital Status:
III
EDUCATIONAL DATA
1. List all high schools, colleges, and professional schools attended and/or attending with the most recent first. If
additional space is needed, place on a separate sheet of paper.
Name of School
City / State
Dates Attended
(mm/year)
Did you graduate?
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
Degree Attained
2. Have you ever attended another nursing program?
☐ Yes
☐ No Office Use Only ☐
If yes, a letter from the program’s dean or director stating eligibility for readmission is required. The letter
must be sent with attention to: Director, Department of Nursing Education.
Name of program:
Dates Attended (mm/year):
3. a. Have you ever taken the NLN Pre-Admission Exam-RN (PAX-RN)?
☐Yes
Date Taken:
Date Taken Must be from October 1, 2014 - May 31, 2017.
b. Have you ever taken the Kaplan Entrance Exam?
☐Yes
Date Taken:
☐No
Date Scheduled:
(Complete number 4-7 only if you are a Licensed Practical Nurse)
4. Name of Practical Nursing program:
Date of program completion:
5. If you have been licensed as a LPN, please answer the following questions?
Which state (s)?
Is license active?
☐Yes
☐ No
☐Yes
☐ No
☐Yes
☐ No
2
Office Use Only ☐
Are you intravenous certified?
☐Yes
☐No
☐Yes
☐No
☐Yes
☐No
6. Have you ever been disciplined by any state or federal regulatory agency or national certifying agency?
☐ Yes
☐ No
If yes, provide details on a separate attached piece of paper.
7. Have you voluntarily entered into an agreement restricting or monitoring your practice?
☐ Yes
☐ No
If yes, provide details on a separate attached piece of paper.
IV.
HEALTH
Core Performance Standards: An applicant seeking admission into the nursing program must meet physical and
psychological requirements essential to providing nursing care.
Do you have any health issues/problems which may affect your course work and/or clinical performance?
☐ Yes
☐ No
If yes, provide details on a separate attached piece of paper.
V.
GENERAL INFORMATION
1) What are your reasons for selecting this profession:
2) Why have you selected Pearl River Community College:
3) What are your strengths and weaknesses as an ADN applicant?
a. Strengths:
b. Weaknesses:
4) List any work experience you have (preferably in the medical field):
Provide details on a separate attached piece of paper.
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5) Are you aware of the following services available at PRCC?
VI.
Admissions
(601) 403-1214
☐ Yes
☐ No
Advising/Counselor Center
(601) 403-1250
☐ Yes
☐ No
Distance Learning
(601) 403-1110
☐ Yes
☐ No
Financial Aid
(601) 403-1029
☐ Yes
☐ No
Student Support Services
(601) 403-1266
☐ Yes
☐ No
ACKNOWLEDGEMENT
I certify that the statements on this application are true and complete to the best of my knowledge,
and that I have attended no institution other than those listed therein. I am aware that falsification
of information is a basis for denying admission or for immediate termination of enrollment.
Applicant’s Signature: _____________________________
4
Date: _________