Fillable Nursing & Allied Health Program Application (Southeast Arkansas College)

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Nursing & Allied Health Program Application (Southeast Arkansas College)

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Rev. 11/10/20
Nursing & Allied Health Program Application
(Choose one)
EMT Basic Medical Coding
EMT Advanced Sterile Processing
Paramedic Practical Nursing
Nursing Assistant Surgical Technology
Level I: Generic RN Radiologic Technology
Level II: LPN/Paramedic to RN Respiratory Therapy
Phlebotomy
ADMISSION REQUIREMENTS: Complete all SEARK College Admission Requirements and general requirements
l
isted below:
1. Completion of all general admission procedures of the College.
2. Completion of competency testing in Reading with a minimum score of:
• ACT: 19
• Compass Reading: 83
• Accuplacer Reading: 75
• Next Generation Accuplacer: 250 OR
3. Completion of a course in Developmental Reading with a grade “C” or better
ACCEPTANCE PROCEDURE: Should qualified applicants exceed the available slots in the program, admission into a
class will be based on the date of completed application. Upon acceptance into the Program, the student must submit the
following to begin classes: The cost of the subscription Drug Screen, and Criminal background check is the student’s
expense. (Not Applicable to all programs.)
1. Functional Ability Acknowledgement Form
2. P.P.D. Skin Test or Chest X-Ray
3. Tdap Vaccination (Must be taken within 10 years)
4. Current Flu Vaccination
5. Hepatitis B Series or Signed Vaccination Waiver Claim Form.
6. Drug Screen
7. Criminal Background Check
The above information must be submitted to:
Southeast Arkansas College
Nursing & Allied Health Technologies Division
1900 S. Hazel St.
Pine Bluff, AR 71603
Students enrolled in Allied Health programs with a clinical component will be assessed a fee for malpractice insurance.
-OR-
Email Completed Application
(from SEARK Student Email)
to
Jscott@seark.edu
Rev. 9/20/19
SOUTHEAST ARKANSAS COLLEGE
NURSING & ALLIED HEALTH APPLICATION
NAME
ADDRESS
CITY
STATE and ZIP
DATE OF BIRTH
SEX:
MALE
FEMALE
STUDENT I.D. #
PHONE NUMBER
PERSONS TO NOTIFY IN CASE OF EMERGENCY:
NAME ADDRESS CITY/STATE PHONE NO.
1.
2.
DO YOU HAVE HOSPITALIZATION OR HEALTH INSURANCE COVERAGE? YES _______ NO __________
PREVIOUS WORK EXPERIENCE (List current employer.)
EMPLOYER CITY/STATE JOB TITLE FROM TO
EDUCATION: HIGHEST GRADE COMPLETED ____ DATE OF GRADUATION OR GED
NAME & ADDRESS OF LAST SCHOOL ATTENDED
HAVE YOU EVER BEEN ENROLLED IN ANY OTHER SCHOOL OF NURSING? YES______ NO_______ If yes, please submit transcript from school of nursing.
ARE YOU CURRENTLY CERTIFIED IN ANY ALLIED HEALTH AREA? YES NO_____ LIST CERTIFICATION_________________________________________
HAS YOUR CERTIFICATION EVER BEEEN ENCUMBERED? YES NO If yes, list reasons and dates of all encumbrances
ARE YOU WILLING TO GO TO ANY AGENCY IN OUR SERVICE AREA FOR YOUR CLINICAL TRAINING? YES _________ NO _____________
REASONS:
PLANS AFTER GRADUATION:
PERSONAL REFERENCES (NO RELATIVES)
NAME COMPLETE ADDRESS PHONE NUMBER
1.
2.
*HAVE YOU EVER BEEN CONVICTED OF A CRIME?” YES_____ NO______ IF YES, PLEASE EXPLAIN:
*Conviction of certain crimes may cause the applicant to be ineligible to do clinical at some clinical sites. This ineligibility may result in suspension from the program.
Random drug screening may be utilized at any time during the program at the student’s expense.
I authorize the college to release information provided by me in application for admission to the NAH program to approval/accrediting agencies and clinical affiliates, as required. This
authorization includes the release of my transcript.
I hereby certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any misrepresentations or a falsification of
information is cause for denial of admission or suspension from the program.
DATE SIGNATURE submission from SEARK Email will suffice as signature
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Nursing & Allied Health Program Application (Southeast Arkansas College)

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Completed 29 January 2021

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