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2022 2023 NURSING PROGRAM APPLICATION ALLIED HEALTH SCIENCES (Mineral Area College)

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Application deadline: 12pm December 15
th
, 2021
Revision Date: 2021-04-07 Page 1 of 2 Initials: _____________
2022 – 2023
NURSING PROGRAM APPLICATION
ALLIED HEALTH SCIENCES DEPARTMENT
SELECT THE PROGRAM(S) APPLYING TO: $20 application fee per program; by check or cash only with paper application
Associate of Science in Nursing (RN) 1
ST
Choice 2
ND
Choice
Program in Practical Nursing (LPN) 1
ST
Choice 2
ND
Choice
Advanced Placement (LPN to RN) I received my LPN from ___________________________________school in (_____)
LPN license #_________________ I am a current PN student at MAC
I am a previous PN graduate from MAC nursing program
ADN Sophomore Reapplication* *must be previous MAC ADN Sophomore
Credentials: ________________________ ________/________/________ ___________________________________
MAC Student ID Date of Birth Social Security Number
Name: _____________________________________________________________________________________________
Last First Middle Maiden
Address: _____________________________________________________________________________________________
Street City State Zip County
Contact Info: ________________________ _________________________ U.S. Citizen Authorized Alien Status
Cell Phone MAC Email Address
Schools: Are you a current High School student*? Yes No * Must graduate from high school by June 2020
Name of Other Colleges City, State Completed Degree Name Last Year Attended
_________________________________ ___________________ ___________________ ______________
_________________________________ ___________________ ___________________ ______________
_________________________________ ___________________ ___________________ ______________
_________________________________ ___________________ ___________________ ______________
Nursing: Have you ever been a student in any nursing program*? Yes* No
* Required for Advanced Placement application
LPN _________________________________ _______________________ _________________
Name of School City, State Dates Attended Degree
_______________________________________________________ _________________ ________________
If ever disciplined by State Board of Nursing or license revoked, explain NCLEX Pass Date LPN License Number
Other _________________________________ _______________________ _________________
Name of School City, State Dates Attended Passing Failing
_____________________________________________________________________________________________
Explain reason for not completing
Page 2 of 2
Convictions: Have you ever been convicted, adjudged guilty by a court, pled guilty or pled nolo contendere to any crime
(excluding traffic violations), whether or not sentence was imposed, in this state or any other state?
Yes No Date: ______/______/______ If yes, please explain: ________________________
______________________________________________________________________________________
Have you ever been arrested or convicted of a sexual offense in this state or any other state?
Yes No Date: ______/______/______ If yes, please explain: ________________________
______________________________________________________________________________________
Test Scores: List your highest Accuplacer Next Generation scores for each test area:
Meets minimum requirement Must test again
Meets minimum requirement Must test again
Meets minimum requirement Must test again
Prerequisites: List your prerequisite courses, equivalent or higher, with highest grade:
Course Grade School Term
English
Math
Chemistry
Grade Point Average: Calculate your selection GPA and write it here: Meets program requirement
Acknowledgements:
By signing below, I acknowledge that I have read, understand and been offered a copy of the
Notice of Entrance Requirements. I confirm that these requirements include academic testing, prerequisites
and GPA criteria. I understand that I am responsible for requesting official transcripts from other
educational institutions. I am aware the deadline for completion and submission of these criteria is
December 15, 2021.
Furthermore, I acknowledge that I have read, understand and been offered a copy of the Notice of
Essential Functions necessary for the nursing program. By signing here, I confirm that I can perform, with
or without reasonable accommodation, the essential functions necessary in the role of a student nurse.
Additionally, I have been offered the Notice of General Policies which includes information
regarding Equal Opportunity at Mineral Area College and the American Disabilities Act. I have also been
provided with information on accessing the Missouri Nursing Practice Act.
Signature: ___________________________________________ ___________________________________
Student Signature Date
FOR OFFICE USE ONLY
Date: _____ /_____ /_____ Staff Initials: __________ Amount Paid: $ __________ Cash Check # ____________
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2022 2023 NURSING PROGRAM APPLICATION ALLIED HEALTH SCIENCES (Mineral Area College)

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Completed 12 July 2021

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