Midway University Nursing Application
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MIDWAY UNIVERSITY ADN and BSN PROGRAM NURSING APPLICATION We are pleased that you are considering the Midway University ADN and/or BSN Program. Midway University is accredited by the Accreditation Commission for Education in Nursing, Inc., 3343 Peachtree Rd., Suite 850, Atlanta, Georgia 30326, Phone: 404-975-5000, Fax: 404-975-5020, www.acenursing.org and has full approval of Kentucky Board of Nursing, 312 Whittington Parkway, Suite 300, Louisville, KY 40222, Phone. 502-429-3300, Fax. 502-429-3311, http://kbn.ky.gov. The following application form should be filled out completely and accurately. All information is kept confidential and is used for the Nursing Program Evaluation process only. This information will not be released to any other entities within or outside of the university unless a written consent is given by you, the applicant. Return pages 1-4 and retain the remaining pages for your records. Mail or hand-deliver application to: Midway University ADN and BSN Nursing Program 512 East Stephens Street Midway, KY 40347-1112 NOTICE OF NON-DISCRIMINATION Midway University does not discriminate on the basis of race, color, religion, sex (including pregnancy and gender identity), national or ethnic origin, disability (physical or mental), genetic information, parental status, sexual orientation, marital status, age, political affiliation or belief or any other protected factor in the administration of its educational policies or in its employment practices. For additional information, contact the University’s Title IX Coordinator: Assistant Vice President for Student Affairs, McManis Student Center, 512 E. Stephens St., Midway, Kentucky 40347-1112, 859.846.5391. Midway University is committed to providing an environment that is safe and provides appropriate motivation to insure a creative and productive work force and academic setting. To this end, Midway University endorses the philosophy that the campus should be free from the detrimental effects of drugs and alcohol. To insure student and worker safety and workplace and classroom integrity, Midway University prohibits the illegal manufacture, possession, distribution, or use of alcohol, controlled substances, and illicit drugs on its campus or as part of any of its activities. Further, except for employees and guests living in private residences of the university or university residences leased for private use, by authority of the Board of Trustees, possession and use of alcoholic beverages on the campus by employees, students, or guests is prohibited. The Midway University Alcohol Policy approved in 2003 limits the serving of alcohol only as approved by the university president. All applicants seeking admission into the Midway University ADN and BSN program must complete an approved Kentucky Medicaid Nurse Aide training course. After completion of the course, applicants must then take and pass the State of Kentucky Medicaid Nurse Aide exam (SRNA). Proof of SRNA must be submitted to the Nursing Office. A copy of the course completion certificate is not sufficient documentation. The SRNA is part of the admissions criteria. Approved Nurse Aide Training Providers Contact: Michelle Fulner Cabinet for Health and Family Services Department for Medicaid Services Division of Healthcare Facilities Management Long Term Care Branch 275 East Main Street, 6 C-B Frankfort, KY 40601 (502) 564-4321 ext. 2282 Bluegrass Community and Technical College Gateway Community and Technical College Medical Career and Technical College Nurse Aide Training 500 Technology Way 630 Eastern Bypass 164 Opportunity Way Florence, KY 41042 Richmond, KY 40475 Lexington, KY 40511 859-441-4500 859-624-1988 859-246-6642 www.gateway.kctcs.edu/academics/programs_o www.bluegrass.kctcs.edu/nursing/nursing_aide f_study/mna Nurse Aide Training School, Inc. 307 Jason Drive, Suite 2 Bluegrass Extra Care Nurse Aide Training Healthcare Training Center of Scott County Richmond, KY 40475 Center 203 Champion Way Suite 5 859-624-4068 2312 Alexandria Drive Georgetown, Ky 40324 www.nurseaideeducation.com/about-nurse- Lexington, KY 40504 502-642-4700 / 1-833-648-9645 aide-training-in-kentucky 855-492-0812 / 859-296-0513 www.htc-ky.com www.bgcarenav.org Red Cross Nurse Aid Training Healthcare Training School 510 E. Chestnut Street Campbellsville University Bardstown, KY PO Box 1675 1 University Drive 502-507-3497 Louisville, KY 40202 Campbellsville, KY 42718 502-561-3771 270-789-5400 www.redcross.org/ky/louisville/nat www.campbellsville.edu/allied- Health Education Center, LLC health/certificate-programs/state-registered- 10508 Nanka Road nurse-aide Louisville, KY 40272 Spencerian College 502-510-1363 1575 Winchester Road www.healtheducationcenter.us Lexington, KY 40505 Campbellsville University-Hodgenville 859-223-9608 813 Old Elizabethtown Road www.spencerian.edu Hodgenville, KY 42748 Kentucky Community and Technical College 270-789-54004 System www.campbellsville.edu/hodgenville (search by school) Spencerian College www.kctcs.edu 4627 Dixie Highway Louisville, KY 40216 Emergency Medical Training Professionals, 502-447-1000 LLC Kentucky Health Care Training Institute www.spencerian.edu 1141 Red Mile Road, Suite 101 3010 Taylor Springs Drive Lexington, KY 40504 Louisville, KY 40220 859-327-3687 502-458-4570 Wisdom and Health Institution www.emtpky.com/srna www.healthcareky.com 3920 Bardstown Road, Second Floor Louisville, KY 40218 502-712-1749 Enrich Me Learning Center KY Health Training www.wisdomandhealthinstitution.com 96 Court Square 343 Waller Avenue, #204 Bardstown, KY 40004 Lexington, KY 40504 502-349-1500 859-963-2901 www.khtnow.com Office Use Only Received: Kentucky Board of Nursing Policy on Requirements for Licensure Applicants with Criminal Convictions State law requires that licensed individuals report criminal convictions to the Kentucky Board of Nursing within ninety (90) days of the conviction, KRS 314.109. Kentucky Board of Nursing Administrative Regulations 201 KAR 20:370, application for licensure and registration, also require applicants to report criminal convictions and states what must be submitted when reported. I have read the Kentucky Board of Nursing Policy on the Requirements for Licensure Applicants with Criminal Convictions and understand these requirements. I also understand that individuals who have a felony conviction are not eligible for placement in clinical courses and so cannot be admitted. Signature Date Kentucky Board of Nursing 312 Whittington Parkway, Suite 300 Louisville, KY 40222-5172 1-800-305-2042 or 502-429-3300, Ext. 238 or 243 http://kbn.ky.gov 1 Revised 2015, 2016, 2018, 2019, 2020 Midway University Nursing Application Select only one program. If unsure discuss with your academic advisor. Associate Degree (ADN) TRD (Day) Track EON Track (ADN only) Bachelor of Science (BSN) Are you a Residential or Commuter student? Before this application is submitted to the Midway University Nursing Department, the student must first be accepted into the University and has also met all the Nursing Admission Program requirement criteria. An incomplete application will not be reviewed. Student ID #: Name: (Last) (First) (Middle) (Maiden Name) Address: (Street or P.O. Box) (Apartment #) (City) (State) (Zip) (Mobile phone) (Home phone) Birthdate: Midway Email Address: Personal Email Address: Ethnic Background (Information is confidential and is requested to fulfill reporting obligations of the University.) African American/Black Asian/Pacific Islands Caucasian/White Hispanic Native American/Alaskan Other Certification/Licensure (choose all that apply) Certification/Licensure Certification / Licensure # Expiration Date State Issued SRNA CMA RMA LPN Are you currently taking classes at Midway University? If so, are you full-time; part-time? What is your Midway GPA? What is your current ACT? List the Colleges and/or Universities you have previously attended beginning with the most recent first. Name and location of institution Dates of attendance Major/Degree(s) earned 2 Revised 2015, 2016, 2018, 2019, 2020 Have you been enrolled in a nursing program in the past? YES NO Were you successful? YES NO If not, how many attempts, ? Include with application a letter of explanation. In addition, the Academic / Clinical Performance Sheet (page 4) must be sent to the former program for completion and returned directly to Midway University Nursing Department by application deadline date, August 1, 2020. All required immunizations and health certifications must be submitted with the nursing application. See pages 5 and 6 for details. Are you currently employed? YES NO (Employer) (Street address) (City/state/zip) (phone #) List work experiences: Have you ever been convicted of a crime? YES NO If yes, a letter of explanation must be included with this application. I have read and understood all the above questions. My answers to these questions are true to the best of my knowledge. (Applicant’s Signature) (Date) 3 Revised 2015, 2016, 2018, 2019, 2020 Academic / Clinical Performance Sheet Name: ID Number: School Name: Telephone: Date enrolled: / to / Month Year Month Year I request that the following information be provided to the Midway University Associate Degree and/or Bachelor of Science Nursing program. I ( do / do not) waive my right under the Buckley Amendment to inspect this reference which will be filed in my student record. Student Signature Date To be completed by the Nursing Program Administrator: The above-named student has applied for admission to the Associate Degree