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161925-121920Collin CollegeNursing Program(s) Admission ApplicationADN Nursing Program_____________________________________________________________________________________________Read the application carefully, complete, sign, and submit with required documents to: Collin College, Nursing Department, 2200 W. University Drive, McKinney, TX 75071. Submitting an application is not a guarantee of acceptance into the program.(Please Select ) FORMCHECKBOX Nursing – Summer Semester 20 FORMTEXT ?????; Submit by January 15th (Starting 2018) Traditional FORMCHECKBOX LVN-RN Bridge FORMCHECKBOX Medic/Paramedic Fast Track FORMCHECKBOX FORMCHECKBOX Nursing – Fall Semester 20 FORMTEXT ?????; Submit by May 31stTraditional FORMCHECKBOX LVN-RN Bridge FORMCHECKBOX Medic/Paramedic Fast Track FORMCHECKBOX FORMCHECKBOX Nursing - Spring Semester 20 FORMTEXT ?????; Submit by August 31stTraditional FORMCHECKBOX LVN-RN Bridge FORMCHECKBOX Medic/Paramedic Fast Track FORMCHECKBOX FORMCHECKBOX HCA North Texas 2-Step - Summer Semester 20 FORMTEXT ?????; Fall Semester 20 FORMTEXT ?????; Spring Semester 20 FORMTEXT ?????;Traditional FORMCHECKBOX LVN-RN Bridge FORMCHECKBOX I. Personal Information (Please Print or Type)Last Name FORMTEXT ?????First Name FORMTEXT ?????MiddleInitial FORMTEXT ?????Other Legal Names Used FORMTEXT ?????Street Address FORMTEXT ?????County FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Home Phone FORMTEXT ?????WorkPhone FORMTEXT ?????Cell Phone FORMTEXT ?????Email Address FORMTEXT ?????Employer FORMTEXT ?????CWID# FORMTEXT ?????Social Security# FORMTEXT ?????Have you submitted an admission application and been accepted at Collin College? FORMCHECKBOX Yes FORMCHECKBOX No If No, please submit an application to the Admissions Office.Have you submitted an application to the Collin College Associate Degree of Nursing program before? If yes, what year? FORMCHECKBOX Yes, Spring: FORMTEXT ????? Summer: FORMTEXT ????? Fall: FORMTEXT ????? FORMCHECKBOX NoII. Academic InformationComplete Academic History (Including Collin College)College(s) attended/attending: Dates attended/attending (most recent first) College Attended Dates FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(Write additional colleges/universities attended on back of form)List any degree(s) or certifications you have earned and your major: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(Write additional colleges/universities attended on back of form)III.PSB - Nursing School Aptitude Exam: Date Completed FORMTEXT ???? ? or Date to Take FORMTEXT ???? ?.**The PSB test may only be taken once per application cycle. Testing Center personnel may end a test session if all directions and procedures are not followed. Failure to complete the test will void the application to the nursing program.IV. FORMCHECKBOX Acknowledgment for LVN-RN and Medic/Paramedic Bridge Programs: HESI Mobility (second entrance exam) will be administered once nursing admission requirements have been met. Nursing Department will contact applicant regarding scheduling.**The HESI Mobility exam is only required for the LVN-RN Bridge and Medic/Paramedic Fast Track programs and benchmark of 850 higher achieve. The exam results are valid for 12 months.IV. EligibilityHave you ever been arrested for anything in your life? FORMCHECKBOX Yes FORMCHECKBOX No If yes you will not be allowed to begin the program until you have been cleared by the Texas Board of Nursing. Contact the Texas Board of Nursing to begin the Declaratory Order process.** (Collin College student applicant ONLY) **Collin College Authorization to Release Academic and Disciplinary RecordsI hereby authorize Collin College - Dean of Students Office, to release information of my academic and disciplinary record to the Collin College Nursing Department as part of the application process for the Associate of Applied Science – Nursing program.Student’s Signature: __________________________________Date: _______________________________VI. FORMTEXT ????? (Initials required) Non-Collin College Students ONLYA Disciplinary Action Disclosure Release must be completed in order to apply. Please complete and submit Exhibit A form to your current or last institution attended. Form must be sent directly from institution (application deadline dates listed on page one will be strictly enforced)Applicant's Signature ___________________________________________ Date _____________________Please provide official transcripts from all colleges attended, including Collin College.Collin College does not discriminate on the basis of race, color, religion, age, sex, national origin, disability or veteran status.Revised: February 2017 ................
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