Fillable Practical Nursing Program Application www.newriver.edu 1. New River (New River Community and Technical College)

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Practical Nursing Program Application www.newriver.edu 1. New River (New River Community and Technical College)

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BROWSE NEW RIVER COMMUNITY AND TECHNICAL COLLEGE FORMS

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PLEASE PRINT OR TYPE
Date of Application ____________________
Name _______________________________________________________________
Last First Middle
List any former last name(s) you have used for work or school:
____________________________________________________________________
Mailing Address_______________________________________________________
Street or P.O. Box where you receive your mail
____________________________________________________________________
City State Zip Code
Telephone____________________________________________________________
Home Work Other
New River CTC Student ID Number _______________________________________
E-Mail Address________________________________________________________
New River CTC e-mail if you have one or personal e-mail address
Preferred method of contact:
oE-mail oMail oPhone__________________
Cohort you wish to apply for:
oGreenbrier Valley oNicholas County oRaleigh County
EMERGENCY CONTACT
Emergency Contact ____________________________________________________
Emergency Contact Phone_______________________________________________
Emergency Contact Relationship _________________________________________
Spouse, Parent, etc.
New River Community and
Technical College Mission
Statement
New River Community and Technical
College provides accessible,
aordable, quality education and
workforce programs to meet the
needs of the region it serves.
Practical Nursing Program
Mission Statement
The nursing faculty of New River
Community and Technical College’s
Practical Nursing Program embrace
the vision and mission statement of
the College.
Our goal is to provide quality,
state-of-the-art educational and
technical experiences that will
enable graduates to successfully
complete the NCLEX-PN licensing
examination, obtain employment as
novice practical nurses in a variety
of healthcare settings and progress
towards advanced nursing education.
Mail completed application to:
Practical Nursing Program
6101 Webster Road
Summersville, WV 26651
Phone: 304.883.2481
Fax: 304.883.2483
Have questions? E-mail
tbryant@newriver.edu or
jperry@newriver.edu
www.newriver.edu
(side 1 of 2)
First-year students must submit*:
1. New River Community and Technical College Application for Admission
2. Application for the Practical Nursing Program
* Please note that new application materials must be submitted each time a student applies to the Practical
Nursing Program.
Practical Nursing
Program Application
EDUCATIONAL BACKGROUND
High School ___________________________ Graduation Date ________________
High School Address __________________________________________________
College ________________________________ Graduation Date _______________
College Address ______________________________________________________
Have you attended any other nursing programs? oYes oNo
Nursing Program _________________________ Date Attended_________________
Program Address______________________________________________________
MOST RECENT WORK EXPERIENCE
Employer ___________________________________________________________
Address ____________________________________________________________
Dates of Employment _________________________________________________
Reason for Leaving ___________________________________________________
BACKGROUND
Previous healthcare experience (please list) ________________________________
___________________________________________________________________
___________________________________________________________________
____________________________________________________________________
Have you ever been convicted of a felony or do you have any felony charge(s)
pending against you at this time? oYes oNo
Have you ever been convicted of a misdemeanor? oYes oNo
Please write 200-300 words about why your are interested in a career in nursing
and why you would like to receive your training through New River CTC’s Practical
Nursing Program. (You can attach your answer on a separate sheet of paper.)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
_________________________________________________________________
New River Community and Technical
College is an Armative Action/Equal
Opportunity Institution, committed to
the principle that minorities, women,
veterans, and individuals with
disabilities are encouraged to apply.
The College does not discriminate
on the basis of race, color, national
origin, ancestry, sex, sexual
orientation, age, religion, blindness,
or disability in its educational
programs or in admission to, access
to, treatment in, or employment as
required by applicable state and
federal law.
The oce listed below has been
designated to handle inquiries
regarding the nondiscrimination
policies, Americans with Disabilities
Act of 1990, Section 504 of the
Vocational Rehabilitation Act of 1973,
and Title IX.
Inquiries from College and
Prospective Employees, Visitors,
Third Parties, Current and Future
Students: Leah Taylor, Vice
President for Administrative Services
and Student Services, New River
Community and Technical College,
280 University Drive, Beaver, WV
25813 Phone:304.929.6701
Mail completed application to:
Practical Nursing Program
6101 Webster Road
Summersville, WV 26651
Phone: 304.883.2481
Fax: 304.883.2483
www.newriver.edu
Revised 9/17 (side 2 of 2)
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Practical Nursing Program Application www.newriver.edu 1. New River (New River Community and Technical College)

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Completed 9 October 2020

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