Fillable Practical Nursing Application Form National Park College 101 (National Park College)

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Practical Nursing Application Form National Park College 101 (National Park College)

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Practical Nursing
Application Form
National Park College
101 College Drive
Hot Springs, Arkansas 71913
(501) 760-4222 or (501) 760-4160
PLEASE PRINT OR TYPE Student ID Number:
Date: Social Security Number:
Full Name:
Last Name First Name Middle Name
Work Phone: Home Phone: Cell Phone:
Current Address:
Number & Street City State Zip Code
Date of Birth:
Do you speak English in your home? Yes No.
Are you a U.S. Citizen? Yes No
Email Address:
High School Attended:
School Name
City State
Date of High School Graduation:
G.E.D. Certification:
Yes No
Do you have a vali
d 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
If you have attended another college, university or other schools, please list them below.
Name of Institution
City & State
Date (From-To)
Degree Received
Are all of your transcripts on file at NPC? Yes No
Have you enrolled in a nursing program previously? Yes No If yes, date and Place:
Have you previously applied to this nursing program? Yes No Date:
List Work Experience:
Employer
Location
Date (From- To)
Description of Work
How did you hear about this program?
Are you applying to more than one nursing program for summer/fall 2020?
Yes
No
If yes, how many? (If you are applying to National Park College RN and PN programs, count this as 2)
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. Thank you.
On a separate sheet of paper, please answer the following questions:
1. Give your reasons for choosing nursing as a career.
2. The practical nursing courses are very time intensive. Classroom (Lecture) meets Monday through Friday for 6
hours per day until clinical begins. Clinical meets two days a week for 8 to 9 hours. What have you done to
prepare to meet this schedule?
Please attach answers to the application
Because a person can find it difficult, if not impossible to obtain a license to practice as a Licensed Practical
Nurse under certain conditions, please answer the following questions:
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 these questions, submit an explanation of the felony and/ or misdemeanor, including dates and specific
details. Place in a sealed envelope addressed to the Dean of Nursing and attach it to this application.
Please save the completed copy of this application and print. To finalize this completed application, submit
a signed hard copy to the Division of Nursing.
Falsifying any records pertinent to this application can lead to ineligibility or immediate dismissal from the nursing
program. Please initial)
IMPORTANT INFORMATION
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
Programs 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 does not discriminate on the basis of race, color, national origin, sex or qualified handicap in any of its policies, practices or procedures. This
provision includes but is not limited to admissions, employment, financial aid and other educational services. Inquiries regarding Title IX, ADA, and Section 504 should
be directed to the Dean of Students Office on the second floor of the Student Commons or by telephoning (501) 760-4229.
11/19
Y:\NURSING\SECRETARY_FOLDER\AccessibleDocuments\PN\Accessible_pn_application2019npc.docx
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Practical Nursing Application Form National Park College 101 (National Park College)

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Completed 22 July 2020

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