RN-BS admission application form



INDIANA STATE UNIVERSITY

COLLEGE OF HEALTH AND HUMAN SERVICES

APPLICATION FOR ADMISSION - UNDERGRADUATE

Academic Program in Nursing Major Code: BS 9321

Nursing – RN – BSN

for applicants with an associate degree or nursing diploma holding an RN license

Instructions: Complete the application on line, print a copy, sign, and submit to the College of Health and Human Services Nursing Distance Education Office (Rm 306) by the appropriate deadline.

Deadlines:

Due October 1 for Spring admission

Due May 1 for Fall admission

Semester you wish to enter the program: Semester Year

Desired Enrollment Status:

PERSONAL INFORMATION

|Name (last) |(First) |(Middle) |University ID number |

| |      |      |      |

|      | | | |

|Maiden/Former Name |Date of Birth (Mo/Day/Yr) |Gender (optional) |

|      |/    /     | |

|Phone |Cellular Phone |E-mail Address |

|    -     -      |    -     -      |      @       .       |

|Address | City State |Zip Code |

|      |     ,       |      -      |

| | | |

|Emergency Contact |Relationship |Emergency Phone |

|      |      | |

| | |    -     -      |

ACADEMIC INFORMATION

|Have you previously earned a degree? Yes No If yes, highest degree earned: |

|Year:      |

| Institution:       Area of|

|Study:       |

|Are you a licensed Registered Nurse? Yes No |

|License number:       |

|Expiration date:       |

|Issuing state:       |

|Number of years in practice:       Submit copy of current license with this application |

I certify that the information provided with this application is true. I understand that admission is competitive and class size is limited. I recognize that failure to complete this application and to submit all of the required documentation may result in denial of admission to the Nursing Program for the desired semester. I acknowledge that I have access to a computer and am able to create, submit, and retrieve documents and documentation electronically. [Recommended Technology].

As part of ISU’s nursing program accreditation requirements and program evaluation requirements, student papers/assignments are collected to show evidence of program outcomes.  I give permission to have any paper/assignment that I complete to be collected for these purposes.

______________________________________________________ ______________

(Signature) (Date)

*Ethnicity:       Did Either / Both of your Parents attend college:

*Information is used for demographic data only, no individual data is released

RN - BSN WORKSHEET FOR ADMISSION PORTFOLIO

(Registered Nurses in the BS Program)

Required Documentation for Admission

This worksheet is designed to help you keep track of what you have and have not collected for your portfolio. Please place an “X” in the boxes next to all of the required documentation you have submitted. Please include all pages of this document in your Admission Portfolio.

University ()

Complete appropriate application to University

Official college transcripts submitted and $25.00 application fee (if applicable) submitted to

Office of Admissions, Indiana State University, John W. Moore Welcome Center, 318 North Sixth Street, Terre Haute, Indiana, USA 47809-1904

Submit copies of the following required documentation to

College of Health and Human Services, Nursing Distance Education Office (Rm 306), 401 N. 4th Street, Terre Haute, IN  47809

Proof of unrestricted licensure as a registered nurse including state and expiration date

Legible copy of current / valid U.S. driver's license

Copy of the paid receipt or Certificate of Insurance for Professional Liability Insurance



Proof of current CPR certification for healthcare provider



Student Outcomes Assessment Memorandum of Understanding form (signed)



Honor Code form (signed)



Proof of national level criminal background check -



Nursing Program Immunization Record



Health History Form



Please include all pages of this document in your Admission Portfolio along with indicated materials and mail by the appropriate deadline dates to

College of Health and Human Services, School of Nursing, Distance Education Office (Rm 306), 401 N. 4th Street, Terre Haute, IN  47809

Retain a copy of all materials for yourself.

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