Fillable Nursing Program Application Form (Note: If no valid (Dallas County Community College)

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Nursing Program Application Form (Note: If no valid (Dallas County Community College)

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The Nursing Program Application Form (Note: If no valid (Dallas County Community College) form is 3 pages long and contains:

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  • 20 check-boxes
  • 61 other fields

Country of origin: US
File type: PDF

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Nursing Program Application Form
Personal Data:
Date: ________________________ Social Security Number ____________________
(Note: If no valid social security number, this application will be rejected.)
Student ID# ______________
Last name: ______________First name: ____________Middle Name: _______________ M
aiden/Other: _____________
Mailing Address: ______________________________City: ____________________ State: _______ Zip ____________
Email address: ___________________________________
Phone Number: H
ome __________________________ Work_______________________ Cell ____________________
In case of emergency, please notify ______________________Relationship____________ Phone __________________
In compliance with the Title VI Civil Rights Act 1964 (Please check one in each area)
Sex: M ____ F ____Race: Asian/Pacific Islander ___ American Indian ___ Hispanic ____White ___ Black ___Other___
Date of Birth: M
onth ______________________ Day _________________ Year ______________
Education:
Name of High School _______________________________________________ Year of Graduation_________
Street A
ddress ________________________________________ City _________________State___ Zip_____
GED Year Completed ________________ GED Test Score ____________________
Are you currently enrolled in a college/university? Y
es _____ No
_____ If Yes, where? __________________________
Previous Colleges/Universities Attended:
Institution: _____________________________Dates attended from: _______ to: _______ Degree: _________________
Institution: _____________________________Dates attended from: _______ to: _______ Degree: _________________
Institution: _____________________________Dates attended f
rom: _______ to: _______ Degree: _________________
(attached additional institutions on a separate sheet and include in application packet)
Have you ever failed been dismissed or withdrawn voluntarily from another nursing program? Yes ______ No ______
If yes, when? __________ Where? _____________________________________________________________
If yes, to the above question, you must have a letter of good standing from the previous dean of the nursing program. The
letter needs to be sent directly from the previous nursing program dean/director to nursingmvc@dcccd.edu
attention
nursing department chair at Dallas College at Mountain View prior to you submitting your application. Licensure or
certifications:
Are you now or have you ever been licensed or credentialed in a health care career? Yes _______ No _______
If yes, are you currently licensed / credentialed in a health care career? Give license number, state, and health care career:
________________________________________________________________________________________
________________________________________________________________________________________
Have you ever applied for a licen
se/credential in a health care career and been denied? Yes
_____ No _____
If yes, please explain:
________________________________________________________________________________________
_________________________________________________________________________________________
Has your license/credential ever been suspended, revoked, or put on probation? Yes_____ No _____
If you have previously been
licensed or credentialed in a health care career, indicate the status and reason for the current
status of licensure/credential: Suspension
_______________ Probation ______________Inactive ___________________
Attach copies of all state/national licenses/certificates.
Citizenship Statement: I understand that some clinical sites/facilities have rules regarding citizenship. If I am not a US
citizen, I may be unable to complete a specific clinical experience and may be given a different experience if available.
Availability of alternate experiences is not guaranteed. Student initials of understanding:
_________
**If you need to provide additional explanations or information, please add an extra sheet of paper labeled with your
name and student ID.
Do you have any healthcare related work experience? If so, where and how many years?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Admission Testing Information:
Have you taken the HESI A2? Yes _____ No _____Score _____ Name of Institution test was taken: _________________
(copy of score report must be i
ncluded with the application)
If not taken, when are you scheduled to take it?
__________________________ Where: __________________________
NOTE: The test must be within 2 years of application deadline and cannot be retaken within 6 (six) months. If you retake
the test, it is your responsibility to inform the application coordinator to replace the current score.
Criminal Background Check:
If accepted into the nursing program, each student must undergo a criminal background check and drug screen in order to
comply with policies of affiliating clinical practice agencies. It shall be the student’s responsibility to comply with
instructions provided upon acceptance. The background check and drug screen will be at the expense of the student.
Students who do not meet this requirement in a timely manner or whose background and/or drug screen does not meet
agency standards will not be able to start the nursing program. The findings of the criminal background check may
preclude licensure or employment. Individuals with a question concerning this should schedule an appointment with the
nursing department chair as well as contact the Texas Board of Nursing. *If accepted to the Nursing program an
additional Criminal background check will be required through the Texas State Board of Nursing.
Legal Information:
Have you ever been convicted of a crime other than a minor traffic violation? Yes _____ No _____
If yes, Date: ___________ Describe: ____________________________________________________________________
____
______________________________________________________________________________________________
Note: Illegal drug use will cause dismissal from the program.
Certificate of Application: I affirm, agree, and/or understand that all statements on this form are true and accurate; any
misrepresentation or omission of material facts may result in my expulsion from any Nursing program. I hereby authorize
Dallas College at Mountain View or other appropriate State investigative agencies to make all necessary investigations
concerning me, my work habits, character, or my action in any transaction. I further authorize and request each former
employer, person given as a reference, educational institution, or organization to provide all information that may be
sought in connection with this application.
I also understand it is my responsibility to read the program information and follow the admission checklist in order to
successfully complete the program admissions process in a timely manner. I should submit all application forms and
transcripts at the same time in one packet and follow-up to make sure my file is complete before the program deadline
date. Additionally, I also understand it is my responsibility to notify the nursing admission coordinator of any changes
(address, name change, etc.) so the program file will remain up-to-date.
Print Name: _
_____________________________Signature: ______________________________Date: ____________
*Important Nursing Program
Information:
Refer to the admission checklist to successfully complete this application process. Check the website for other
information and forms. For questions or problems, call the Coordinator of Academic Programs at 214-860-3694. Please
submit all materials once completed, to nursingmvc@dcccd.edu
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Nursing Program Application Form (Note: If no valid (Dallas County Community College)

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Completed 22 February 2021

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