Missouri Valley College - School of Nursing Application

(To be completed the semester prior to entering the nursing program) Directions: Complete application and submit along with other required materials to the Nursing Administrative Assistant or the Program Director. For current Missouri Valley College Students complete the application process by February 1st . Transfer and late application students must complete the application process by April 1st. Applications not completed and submitted by April 1st may not be selected as applicants for entering the nursing program.

Name Last First Middle Maiden

Address Street City State Zip Code

Phone Home Work Cell

Email Address: (MoVal email preferred, if applicable (Required)

TOEFL score International students or students with English as a second language are required to take the International Student examination prior to the application deadline. (International and ESL applicants are required to have a minimum TOEFL score of 90: PB 565, CB 225, IB 85).

For completed TOEFL, please submit your score: input score here (evidence of completion should be submitted with application.) or date exam taken: ______

Date of Birth (mm/dd/yyyy) Sex (Optional) M F

Ethnic Origin (check one - Optional)

Asian or Pacific Islander American Indian or Native Alaskan Hispanic/Latino White Non-Hispanic Black Non-Hispanic Other

Colleges/Universities attended other than Missouri Valley:

Name: Dates attended:

Revised 7/2015, 8/2015, 1/2016, 3/2016, 1/2017 Students must have a minimum of ‘B’ in all nursing pre-requisite courses. Students must have a minimum of 2.75 cumulative and Nursing GPA for the selected foundation courses and meet other program criteria outlined on the MVC Nursing website. After admission to the nursing program, students must pass all coursework with a minimum of ‘B’ to continue in the program.

“I acknowledge that all information on this application is true to the best of my knowledge and that if accepted into Missouri Valley BSN program, I will be financially liable for obtaining all required immunizations, a drug screen, CPR for Health Professions certification, malpractice insurance and other items required for the clinical portion of this program.

I have read The Missouri Revised Statutes, Section 335.066 from the State Board of nursing (available on the MVC Nursing Website) and understand that acceptance into the program and completion of the nursing program does not guarantee eligibility to take the Missouri State Licensure exam.

I have read the instructions and understand that refusal of admission or cancellation of registration will result from misrepresentation in any portion of the application form.”

Signature______Date______

HEALTHCARE EXPERIENCE

Are you currently a CNA Years , LPN Years

NURSING RELATED EDUCATIONAL EXPERIENCES (i.e., workshops, camps, internships, job shadowing, or certifications)

Revised 7/2015, 8/2015, 1/2016, 3/2016, 1/2017 ACADEMIC AND WORK HISTORY

Complete the following sections or attach a resume containing the information below. You may add space in a section if needed.

ACADEMIC HONORS OR AWARDS (i.e., deans list, scholarships obtained):

EXTRACURRICULAR ACTIVITIES IN HIGH SCHOOL AND COLLEGE (i.e., clubs, athletics, volunteer, church functions, community activities):

HEALTH CARE RELATED WORK EXPERIENCE (i.e., lifeguarding or any other healthcare exp.):

CERTIFICATIONS RECEIVED (i.e., CPR, first aid, lifeguard, personal training, CNA, CMT):

PREVIOUS WORK HISTORY (i.e., summer jobs, employment history not described above):

OTHER INFORMATION (include any additional information about yourself which does not fit into the previous categories):

REFERENCES

List the individuals who will be providing your references. The MVC Nursing reference form and directions are located on the Nursing website under “Application Requirements.”

Reference 1: Reference 2: Reference 3:

Name and Credentials Name and Credentials Name and Credentials

PREREQUISITE COURSES Revised 7/2015, 8/2015, 1/2016, 3/2016, 1/2017 The following courses must be passed with a minimum of “B” in each course (except College Algebra must be a “C” or higher) while maintaining a minimum cumulative Nursing GPA of 2.75.

Human Anatomy & Physiology I & II Microbiology Pathophysiology Introduction to Nursing College Algebra or higher Biomedical Ethics Developmental Psychology

Additionally, the MVC Core Coursework must be completed.

If you do not complete the prerequisite courses listed above with at least a “B”, do not complete the MVC Core Courses or believe you will not meet the minimum Nursing GPA requirement of 2.75 by the end of the spring semester, you are required to submit a detailed plan of action using the Special Request Form on how you plan to meet the deficiencies by August 1st. This form is located on the nursing website.

CRIMINAL BACKGROUND

Have you ever been convicted of a crime? Yes ______No______Describe:______

You will be required to submit to a criminal background check upon acceptance to the nursing program.

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I have answered all of the above questions to the best of my knowledge completely and truthfully.

______Signature of Applicant

______Date

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Missouri Valley College School of Nursing is credentialed by the Commission on Collegiate Nursing Education (CCNE) and has initial approval of the Missouri State Board of Nursing.

The Nursing program objectives as well as the admission criteria, advanced placement policies, student services, curriculum, program cost, refund policy, and financial assistance can be found on the Nursing

Revised 7/2015, 8/2015, 1/2016, 3/2016, 1/2017 and Missouri Valley College websites. All interested applicants are encouraged to visit the Nursing website and read the BSN Student Handbook.

Please submit all application materials by the due date listed above to the Missouri Valley College School of Nursing Administrative Assistant or the Program Director.

Missouri Valley College Nursing Program Application 500 E. College Marshall, MO 65340 P: 660-831-4053 F: 660-831-0975

Revised 7/2015, 8/2015, 1/2016, 3/2016, 1/2017 Missouri Valley College Nursing Program Application for Admission Check-off List

Ensure the following information is completed and submitted by the deadline listed above. It is recommended that your application be received before any other documents (i.e., transcripts, reference forms).

Application Form

Application Fee ($25)

3 Reference Forms – The reference form and directions are located separately on the MVC Nursing website under “Application Requirements”

1 From an RN (for LPN students)/if none LPN student use a Supervisor/Counselor/Pastor

1 From a Professor or Instructor

1 From another individual of your choice who IS NOT a family member

Official Transcripts (Transfer Students and Credits Only – all Missouri Valley College coursework grades are available to selection committee)

ACT (20 or above preferred)

TEAS Exam Score (Score of Proficient or above) - If taken at Missouri Valley College, the score is already available to selection committee. If taken at another institution, the student is responsible for providing an official copy the score with the application.

TOEFL Score for International or ESL Students - Student must score a 90.

GPA (Overall 2.75)

Special Request Form (If Applicable)