Fillable RN Application SPRING 2020 MT (Mt. San Jacinto Community College District)

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RN Application SPRING 2020 MT (Mt. San Jacinto Community College District)

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ADN/RN Updated: 8/30/2019
Page 1 of 5
MT. SAN JACINTO COLLEGE
ASSOCIATE DEGREE IN NURSING (RN) APPLICATION
Filing Periods: September 3
rd
– September 17
th
for Spring 2020 admission
Office Hours: Monday – Thursday 8:00am to 5:00pm and Friday 8:00am to 12:00pm
**Please review the MSJC College Calendar for holidays & college closures as they may occur during the
application filing periods listed above.
It is the student’s responsibility to request and ensure that all documents are in the Nursing & Allied Health
Office by the application deadline.
INCOMPLETE or INACCURATE application packets will automatically disqualify the applicant.
Applications must be hand delivered in person to the Nursing & Allied Health Office located on the
Menifee Valley Campus, Building 500.
Correspondence with students regarding application status will be communicated via
MSJC student email only.
Applicants must have received an Eligibility Letter to be able to apply.
A copy of the Eligibility Letter and entire evaluation must be submitted with the application.
Date:
Last Name (Please Print) First Name Middle Name (Initial)
___________________________________________
Previous name (Please Print) Previous name (Please Print)
MSJC Student ID # Email Address (MSJC Student Email Only)
Mailing Address City State Zip
( ) ( )
Primary Phone # Alternate Phone #
TEAS Results:
Adjusted Individual Score: Date TEAS was taken:
Institution TEAS was taken at:
Please submit the following WITH your application: A copy of your UNOFFICIAL TEAS scores.
Purchase OFFICIAL TEAS transcript/score through ATI (results must be sent directly from ATI to MSJC ADN Program)
Contact MSJC Nursing Department [via phone (951)639-5578] to verify that your official TEAS scores were received.
RN
ADN/RN Updated: 8/30/2019
Page 2 of 5
MT. SAN JACINTO COLLEGE
ASSOCIATE DEGREE IN NURSING (RN) APPLICATION
Initial
(Student)
Initial
(Staff Confirmation)
1. Copy of Complete Transcript Evaluation/Eligibility Letter
________________
________________
2. Copy of Current California Health Care Provider License and/or
Certificate (See Section 1. from the Multi-Criteria Selection
Process for a list of approved licenses and/or certificates.
Applicant must be in good standing with licensing board)
________________
________________
3. Copy of High School Diploma, GED, California Proficiency Exam,
or Degree from an Accredited College or University
________________
________________
4. Have you ever been convicted of a felony/misdemeanor? YES NO
5. Have you ever violated the Student Code of Conduct at any College and/or University? YES NO
6. Have you ever had any of the licenses and/or certificates listed above (Question #2) suspended or
revoked? YES NO N/A
***If you marked yes to any of the above questions (4, 5, and/or 6), you must attach a one page
statement explaining the incident and any supporting documentation. Marking yes, does not disqualify you from the
program, but assists the program faculty to develop a strategic plan to help you be successful in the program. If you
fail to submit your one page statement, your application will not be reviewed and you will be ineligible for
admission consideration.***
7. Life Experiences or Special Circumstances:
A maximum of 5 points will be applied to one area only. Please mark the appropriate boxes and
attach criteria/application requirement (as noted on the Multi-Criteria Selection Process form).
a. Veteran or Active military status
□ NO
b. Disabilities
□ NO
c. Low Family Income
□ NO
d. First generation of family to attend college
□ NO
e. Need to work during pre-requisites
□ NO
f. Disadvantage, social or educational environment
□ NO
g. Difficult personal and/or family situations or circumstances
□ NO
h. Refugee
□ NO
8. Proficiency or Advanced Level Coursework in Languages other than English.
a. Circle the language in which you are proficient:
American Sign Language, Arabic, Chinese (including various dialects), Farsi, Russian, Spanish,
Tagalog, Languages of Indian Subcontinent & Southeast Asia
b. Check the appropriate box that supports your proficiency in the above language:
Two (2) semesters of the same foreign language from a U.S. regionally accredited College
or University (attach transcript if not verified on Transcript Evaluation)
Identified language above is spoken at home (Verification must be provided upon
request).
9. Documented relevant work or volunteer experience in Health Care within the last 3 years. (Attach
proof to support work or volunteer experience) YES NO
ADN/RN Updated: 8/30/2019
Page 3 of 5
MT. SAN JACINTO COLLEGE
ASSOCIATE DEGREE IN NURSING (RN) APPLICATION
10. Approximate Expenses: I agree to the cost of tuition, ASB, parking permit as stated in the current
MSJC catalog, Nursing uniforms ($300), textbooks and supplies ($2000), CPR course ($60-$65),
Physical examination ($300) My CB (CastleBranch) Background and Immunization Clearance
($121.75), Licensing Board Application ($400), ATI testing materials ($600), the Student Supply Kits
($150.00), Professional Liability Insurance ($35 a year) and Health Insurance (cost varies),
Fingerprinting for Mental Health Course ($60-$70).
I understand the approximate expenses for participation in the Associate Degree Nursing Program
and I am aware that expenses are subject to changes.
Change in name/address/phone number must be submitted to the Nursing Office in writing. Your
admission will be compromised if you are unable to be reached.
All Students must have one of the following: Proof of High School Diploma, G.E.D., California
Proficiency Exam, or a Degree from an accredited College or University. If not verified on Eligibility
letter, you must submit documents with application.
All Students must have a Social Security Number that qualifies for employment in the United
States.
I hereby give permission for Enrollment Services to share information (including transcripts,
grades, and evaluation results) with MSJC’s Department of Nursing and Allied Health.
To the best of my knowledge, the above information is true and accurate. Failure to disclose
accurate information will result in your application being removed from consideration and/or
dismissal from program upon acceptance.
Please sign below indicating you have read all the above statements.
Student Signature: Date:
**We strongly recommend that all students check their email daily for communication from the Associate
Degree Nursing Program on a desktop computer as items may be missed when viewing on a tablet or
smartphone.
***Notification of acceptance/denial into the program will be sent via MSJC student email. Please start
checking your MSJC student email within 15-30 days from closure of the application filing period.
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ADN/RN Updated: 8/30/2019
Page 4 of 5
MT. SAN JACINTO COLLEGE
ASSOCIATE DEGREE IN NURSING (RN) APPLICATION
STUDENT DEMOGRAPHIC DATA SURVEY
Semester Entering: SPRING Year: 2020
Instructions: Read each statement and mark your response in the bubble. Do not provide your name.
1. Age:
25 or younger 26-30 years
31-40 years 41-50 years
51-60 years 61 years and older
Age when applying to the ADN program:
2. Gender:
Female
Male
3. Ethnicity:
American Indian Black or African American
Alaska Native Hispanic or Latino
Asian Native Hawaiian or Pacific Islander
o Chinese White/Caucasian
o Filipino Other
o Japanese
o Korean
o Malaysians
o Pakistanis
o Asian Indian
o Thai
o Other
4. Veteran:
Yes
No
5. Do you have dependents (e.g., children under the age of 18, parents or grandparents) living with you?
Yes
No
6. Number of children living at home:
None
1
2
3
4 or more
7. Family status:
Divorced
Single
Married
Widowed
Separated
8. One-way travel distance from residence to campus:
0-10 miles
11-20 miles 31-40 miles
21-30 miles 41 or more miles
ADN/RN Updated: 8/30/2019
Page 5 of 5
MT. SAN JACINTO COLLEGE
ASSOCIATE DEGREE IN NURSING (RN) APPLICATION
STUDENT DEMOGRAPHIC DATA SURVEY CONT.
9. Average weekly hours of employment:
Currently not working
Less than 8 hours
8 hours, but less than 16
16 hours, but less than 24
24 hours, but less than 32
32 hours, but less than 40
40 hours or more
10. Have you had previous experience in health care? (Including Military Education/Coursework)
Yes
No
11. Years working health care:
None
Less than 1 year
1 year, but less than 3 years
3 years, but less than 6 years
6 years, but less than 9 years
9 years or more
12. Health occupations experience:
None
College course: community involvement
College course: paid work experience
Licensed Vocational Nurse
Certified Nurse Assistant
Volunteer work in a health care setting
Paid work experience in a health care setting
Military education/coursework
Other
13. Highest educational level completed:
High school/GED Associate degree
Bachelor’s degree Master’s degree or above
14. Did you move from out of state to attend this program?
Yes
No
15. Program prerequisite courses taken at this college:
Anatomy & Physiology (ANAT 101 & 102)
Freshmen Composition (ENGL 101)
Intermediate Algebra (MATH 096)
Microbiology (BIOL 125)
Not Applicable
16. Do you receive a scholarship or financial aid? Mark all that apply.
Pell Grant GAIN
Employer Local organization scholarship
n/a
17. Are you eligible to receive a BOGG Grant through any of the following: Pell Grant, GAIN, JOBS, JTPA, SST,
General Assistance, AFOC, any other form of economic public assistance, and/or annual income level below
$7,500 for single person, $15,000 per couple with $1,000 additional for dependent child?
Yes
No
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RN Application SPRING 2020 MT (Mt. San Jacinto Community College District)

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Completed 25 July 2020

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