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___________

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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:

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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

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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: ____________________________________

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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.

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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.

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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.

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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.

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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.

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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.

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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.