Fillable Rio Hondo College Health Science & Nursing Division (Rio Hondo College)

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Rio Hondo College Health Science & Nursing Division (Rio Hondo College)

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  • 11 check-boxes
  • 30 other fields

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File type: PDF

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Rio Hondo College
Health Science & Nursing Division
Associate Degree Nursing Program
Application
LVN to ADN
Generic ADN:
Psychiatric Technician to ADN
PERSONAL INFORMATION
Last Name: First Name: M.I.
Street Address:
City:
State:
Zip Code:
Phone Number: Cell Phone:
E-mail Address:
RHC I.D. #: Female Male
Social Security:
Name of person to
notify in case of
Emergency:
Phone Number:
EDUCATION
High School Attended:
Transcripts Attached:
High School Diploma
Attached:
GED:
College Attended:
Street Address:
City:
State: Zip Code:
All Official College
Transcripts Required:
Sent to
Admissions/
Records
Yes
No
ADN Program Track:
Transfer from another ADN
Program
LVN to RN
30 Unit Option
If you are an International Student-
Official International
Evaluation with G.P.A:
Sent to
Admissions/
Records
Yes
No
List Current Medical/Nursing Certificates and/or Licenses (Provide copies)
List Current Health Care work or Volunteer experience (provide proof on letterhead, within last 3 years)
Verification of Life Experience - must provide proof if applicable. (May check up to five areas)
a. Disabilities - The same meaning as used in Section 2626 of the unemployment insurance code.
b. Low Family Income - measured in terms of a student's eligibility for, or receipt of, financial aid under a program
that may include, but is not necessarily limited to, a fee waiver from the Board of Governors, the Cal Grant
Program, the Federal Pell Grant or Cal/WORKS.
c.
Need to work - the student is working at least part-time while completing academic work that is a pre-requisite for
admission to the nursing program.
d. First generation of family to attend college.
e. Disadvantaged social or educational enviroment.
f. Difficult personal and family situations or circumstances.
g.
Refugee or military veteran status.
List all languages that
you are proficient, both
verbal and written
(provide proficiency
test results or College
advanced level course
work on transcripts).
Provide ATI TEAS
results which must be
sent directly from ATI.
(1st time results
accepted only).
If you currently hold an LVN or Psychiatric Technician License, please complete the following:
LVN / PT School attended:
Date of Graduation
License Number
Applying for the:
Did you challenge the
California LVN-NCLEX
or Psychiatric Technician
Examination?
Have you ever been accepted into any Rio Hondo College
nursing programs?
Yes
No
If so, which program?
Signature:
Date:
I understand I may not add any additional documents to this application once it has been submitted.
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Rio Hondo College Health Science & Nursing Division (Rio Hondo College)

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Completed 26 January 2021

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