Imperial Valley College ADRN Program Application Page 3
List All Colleges Attended Include IVC Dates Attended Degree Awarded
Do you have a current Certification/License in an Allied Health Program (EMT, CNA, MA)? Yes No
Do you have recent healthcare work or volunteer experience (recent and more than 100 hours?) Yes No
Do you have a degree (AA/AS, BA/BS, and/or MA/MS)? Yes No
Do you have a current LVN License? Yes No
Current or recent employer
Dates employed
Please answer the questions below. No documentation is needed, only if you answer "yes" for a documented disability:
Are you a Military Veteran or spouse of a Veteran? Yes No
Do you have a documented disability? Yes No Include brief description of disability
Are you a documented refugee? Yes No
Are you eligible to receive Financial Aid, CalWorks, BOGFW-B, Federal Pell grants or EOPS? Yes No
Did you need to work while completing the prerequisite courses to the Nursing Program? Yes No
Are you the first generation of your family to attend college? Yes No
Have you had recent difficult family or personal circumstances (pertaining to single parent, deployed spouse, family caregiver,
death of family member in past 6 months, medical problem, or financial issue? Yes No
Alternate Language Proficiency: If answered yes below, documentation is required
Can you speak, read, and write in any of the languages below in a healthcare setting, OR have you completed an advanced level
course in a foreign language? Yes No Check language and list course and provide verification
of proficiency:
American Sign , Spanish , Tagalog , Arabic , Chinese , Farsi , Russian Indian Subcontinent
Southeast Asia , Other:
Have you been convicted at any time of a felony, misdemeanor, or been cited for a traffic violation of more than $1,000?
Yes No If Yes, you must disclose when applying. Attach a typed, one page statement describing incident – see below.
Previous convictions: When applying for the RN license, the CA Board of Registered Nursing www.rn.ca.gov states that they will consider the nature,
severity, and recency of the offense(s), as well as rehabilitation and other factors, but cannot make a determination for approval or denial of a
licensure without evaluating the entire (licensure) application and supporting documentation. IVC Nursing applicants are therefore, required to submit a
typed statement with the application identifying all occurrence(s). A background check and drug screen will be required if admitted to the program. Failure to
disclose this information (including expunged convictions) will disqualify the applicant, or cause dismissal from the Nursing Program. The IVC
Nursing Program does not make a determination whether a student with a past history of criminal activity should or should not apply.
I certify that the answers I have given are true and I have not withheld any facts or circumstances. I have submitted all
documentation necessary to consider my application in full. I understand that all answers given are subject to verification, and any
falsification, misrepresentation, or omission of facts are sufficient reason for dismissal if discovery at any time during enrollment in
the IVC Nursing Program.
Applicant Signature: Date:
Completed applications will be accepted via email. Please send all attachments in PDF format to Analisa Veliz, Nursing
Administrative Secretary at analisa.veliz@imperial.edu
.
• Completion of prerequisites does not guarantee admission. Incomplete applications will not be considered.
• Proof of equivalency of prerequisites not taken at IVC is mandatory with application. The nursing counselor can assist if any questions.
• Students are notified by email of the status of their application 30-45 days after deadline. Any changes should be reported to the Nursing
Office via email, analisa.veliz@imperial.edu
.
