ࡱ> c Vbjbj AObObT` ` 8(,Td0zL"""!d9#///////$X25/###/""0)))#F""/)#/)))"I3$j)/000)5$5))\5))###//Y'D###0####5#########` B : 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  FORMDROPDOWN  Year  FORMDROPDOWN  Desired Enrollment Status:  FORMDROPDOWN  PERSONAL INFORMATION Name (last)  FORMTEXT       (First)  FORMTEXT      (Middle)  FORMTEXT      University ID number  FORMTEXT      Maiden/Former Name  FORMTEXT      Date of Birth (Mo/Day/Yr)  FORMDROPDOWN  /  FORMTEXT    / FORMTEXT      Gender (optional)  FORMDROPDOWN  Phone  FORMTEXT     -  FORMTEXT     -  FORMTEXT      Cellular Phone  FORMTEXT     -  FORMTEXT     -  FORMTEXT      E-mail Address  FORMTEXT       @  FORMTEXT       .  FORMTEXT      Address  FORMTEXT        City State  FORMTEXT      ,  FORMTEXT       Zip Code  FORMTEXT       -  FORMTEXT     Emergency Contact  FORMTEXT       Relationship  FORMTEXT       Emergency Phone  FORMTEXT     -  FORMTEXT     -  FORMTEXT      ACADEMIC INFORMATION Have you previously earned a degree?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, highest degree earned: FORMDROPDOWN  Year:  FORMTEXT       Institution:  FORMTEXT       Area of Study:  FORMTEXT      Are you a licensed Registered Nurse?  FORMCHECKBOX Yes  FORMCHECKBOX  No License number:  FORMTEXT       Expiration date:  FORMTEXT       Issuing state:  FORMTEXT       Number of years in practice:  FORMTEXT       Submit copy of current license with this applicationI 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. [HYPERLINK "http://www.indstate.edu/oit/students/minimum-specs.php"Recommended Technology]. As part of ISUs 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:  FORMTEXT       Did Either / Both of your Parents attend college:  FORMDROPDOWN  *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. 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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  FORMCHECKBOX  Proof of unrestricted licensure as a registered nurse including state and expiration date  FORMCHECKBOX  Legible copy of current / valid U.S. driver's license  FORMCHECKBOX  Copy of the paid receipt or Certificate of Insurance for Professional Liability Insurance  HYPERLINK "http://www.indstate.edu/health/bnc-professional-liability-insurance" http://www.indstate.edu/health/bnc-professional-liability-insurance  FORMCHECKBOX  Proof of current CPR certification for healthcare provider  HYPERLINK "https://www.indstate.edu/health/bnc-cpr-policy" https://www.indstate.edu/health/bnc-cpr-policy  FORMCHECKBOX  Student Outcomes Assessment Memorandum of Understanding form (signed)  HYPERLINK "http://www.indstate.edu/health/rn-bsn-student-outcomes-assessment-mou" http://www.indstate.edu/health/rn-bsn-student-outcomes-assessment-mou  FORMCHECKBOX  FORMCHECKBOX  Honor Code form (signed)  HYPERLINK "https://www.indstate.edu/health/bnc-honor-code" https://www.indstate.edu/health/bnc-honor-code  FORMCHECKBOX  Proof of national level criminal background check -  HYPERLINK "https://www.indstate.edu/health/nursing-program-criminal-background-check-procedure" https://www.indstate.edu/health/nursing-program-criminal-background-check-procedure  FORMCHECKBOX  Nursing Program Immunization Record  HYPERLINK "https://www.indstate.edu/health/nursing-programs-immunization-record" https://www.indstate.edu/health/nursing-programs-immunization-record  FORMCHECKBOX  Health History Form  HYPERLINK "http://www.indstate.edu/health/sites/health.indstate.edu/files/bnc-health-form.doc" http://www.indstate.edu/health/sites/health.indstate.edu/files/bnc-health-form.doc  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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