NATIONAL PARK COLLEGE
REGISTERED NURSING PROGRAM APPLICATION FORM
Date: Advisor:
Social Security:
NPC ID:
Print Name in Full:
Last Name First Name Middle Name
Cell Phone:
Home Telephone:
Mailing Address:
Number & Street City State Zip Code
Date of Birth: Do you have a valid U.S. Social Security number? Yes No
I understand a valid Social Security number is required to apply for nursing licensure in Arkansas: Yes No
Are you a U.S. Citizen? Yes No Do you speak English in your home? Yes No
High School:
School Name City State
Date of High School Graduation: Month: Year: G.E.D Certification: Yes No
Are you an LPN or LPTN? Yes No If Yes, LPN License Number: State of licensure:
Li
cense expiration date: Hours of wor
k experience as an LPN/LPTN within the past year:
As an LPN/LPT
N, I request advanced p
lacement: Yes No
List information concerning college, university, or other schools attended:
Name of Institution City & State Dates (From - To) Degree Received
List Work Experience:
Employer Location Dates (From - To) Description of Work
If you have ever attended a school of Nursing, RN, or LPN, give the following information:
Name of School City & State Dates (From - To) Reason for Leaving
Have you previously applied to this nursing program? Yes No Date:
When do you desire to begin the major nursing courses?
(Please complete page 2)
Y:\NURSING\SECRETARY_FOLDER\AccessibleDocuments\RN\accessiblern_application_NPC 2019_2020.docx :
(Revised 19)
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY: Between 8:00 a.m. - 4:00 p.m.
Name:
Relationship:
Cell Phone Number:
Work Phone:
How did you hear about this program?
In addition to the NPC RN program are you applying to more than one nursing program? Yes No
If yes, indicate names of other Nursing Programs:
Please Note: If you are applying to the NPC Practical Nursing Program, you must
complete a separate PN application and submit to the Division of Nursing.
This information does not influence your admission status, it serves to provide state information regarding number of students interested in pursuing a degree in
nursing.
ON A SEPARATE SHEET OF PAPER PLEASE ANSWER
THE FOLLOWING QUESTIONS:
1. Give your reasons for choosing nursing as a career.
2. The nursing courses require a great deal of preparation and study time outside of class. What planning have you done
to provide for this?
3. What are your future goals?
BECAUSE A PERSON CAN FIND IT DIFFICULT, IF NOT IMPOSSIBLE, TO OBTAIN A LICENSE TO PRACTICE
AS A REGISTERED NURSE UNDER CERTAIN CONDITIONS, PLEASE ANSWER THE FOLLOWING QUESTION:
All admissions are conditional pending a criminal backgroud check and drug screen
1. Have you ever been convicted of a felony or a misdemeanor? Yes No
2. Do you have a felony charge pending? Yes No
If yes on either of the previous questions, submit an explanation of the felony and/ or misdemeanor, including dates
and specific details. Place it in a sealed envelope addressed to the Dean of Nursing and attach it to this application.
3. Have you ever had a nursing license in the past?
Yes No
IMPORTANT INFORMATION:
Please save the completed copy of this application and print. To finalize this application, submit a signed
hard copy to the Division of Nursing
Refer to the NPC website or the NPC catalog for the essential functions and/or technical standards required for each Nursing
and Allied Health program before submission of this application. National Park College provides academic accommodations as
mandated by ADA and 504. Please contact NPC’s Compliance officer at 760-4227 for reasonable accommodations under the
American’s with Dis
abilities Act (ADA) and for disability assistance information.
Fal
sifying any records pertinent to this application can lead to ineligibility or immediate dismissal from the Nursing Program. I
understand that falsifying my application is dishonest and demonstrates a lack of integrity which could compromise my
acceptance and/or licensure. (PLEASE INITIAL)
I understand the health care industry requires a criminal background check and drug screening upon employment and random
drug testing throughout employment. I also understand that a criminal background check will be required at the time of
admission to the program. I understand that the Substance Abuse Policy of NPC Nursing Program may require drug testing
during my enrollment for the following reasons: 1) Upon admission into the program. 2) Scheduled testing at unannounced
times throughout the program. 3) Random testing as required by the clinical agencies. 4) For cause.
Signature: Date:
National Park College in compliance with Title VI of t he Civil Rights Act of 1964 and Title I X
of the Education Amendments of 1972 Higher Education Act does not
discriminate on
the basis of race, color, nationa l orig in, sex, or qualified handicap in any of its policies, practices, or procedures. The provision includes, but is
not limited to, admissions, employment, financial aid, and other educational services. Any person having inquiries concerning NPC compliance with Title IX is
directed to contact the Dean of Students Office on the second floor of the Student Commons or by telephoning (501)760-4229.
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