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 and/or Bachelor of Science Nursing program at Midway University and has requested the following information be provided to Midway.
Student was enrolled in which program? ADN BSN
Was the student’s performance satisfactory in all areas while in your program? YES NO If not, please indicate any deficiencies by checking the appropriate category(ies) below. Course student was unsuccessful in: Nursing theory grade below passing. Clinical performance unsatisfactory. Withdrew from course(s) in which performance was deficient at the time of withdrawal. Other (Please describe).
Did this student apply for readmission to your program? YES NO
Is this student eligible for readmission to your program? YES NO
If not eligible for readmission, please list reason(s):
Please comment on your opinion of the applicant’s potential for success:
Signature/Title Date
Nursing Program Administrator: Please return this form to Midway University, Nursing Department, 512 East Stephens Street, Midway, Kentucky 40347-1112.
4 Revised 2015, 2016, 2018, 2019, 2020
IMMUNIZATIONS AND HEALTH CERTIFICATIONS
All required immunizations, certifications, and other items listed below are to be submitted to the Nursing Office with application. No student will be allowed to attend clinical rotations until these requirements are met and appropriate documentation is on file. This is a clinical absence and the Clinical Absence Policy will be followed. The clinical absence policy is in the Nursing Student Handbooks, which will be available at the beginning of the first nursing course after admission to the program.
Once an applicant has been accepted into the nursing program, they will be required to create an account with CastleBranch to complete a background check, drug screen and upload immunization documents through a compliance tracking system (Fee required). Information will be included with your acceptance letter on how to proceed with this process. Because of clinical facilities’ requirements, students that do not pass the background check or drug screen will have their acceptance to the program revoked.
MMR (Measles (Rubeola), Mumps, and Rubella) 1. Official immunization record containing 2 documented MMR vaccination dates or; 2. IgG Antibody Titer results showing positive immunity for each component of MMR
Varicella (Chicken Pox) 1. Official immunization record containing 2 documented varicella vaccination dates or; 2. IgG Antibody Titer result showing positive immunity for varicella *Note: A history of an active case of chicken pox is not acceptable as documentation.
Hepatitis B 1. Official immunization record containing dates of 3 doses of Hepatitis B vaccine administered at appropriate intervals as indicated by the healthcare provider or; 2. Hepatitis B Surface Antibody Titer results showing positive immunity for Hepatitis B or; 3. If a student does not wish to obtain the Hepatitis B vaccine or is not complete with the series, the Hepatitis B Waiver form (included) should be signed and submitted with this application. Should the student complete the vaccine series or obtain a titer at a later date, it is the student’s responsibility to submit documentation to the Nursing Office.
Tdap (Tetanus, diphtheria, acellular pertussis) 1. A one-time adult dose of Tdap vaccination is required.
Influenza Vaccination Clinical sites contracted with Midway University’s nursing program require employees and students to provide documentation of influenza vaccination during the flu season; all flu documentation due by October 31. Any deferments would need to be approved by the contracted site. Those who are not vaccinated will be required to wear a mask while on the unit during flu season.
CPR 1. Infant, Child, and Adult Resuscitation are required for certification. 2. American Heart Association Basic Life Support for the Healthcare Provider is the only certification acceptable. 3. Student must sign and submit a front and back copy of the CPR card. Certification must not lapse while in the ADN and/or BSN program. It is the student’s responsibility to recertify and submit documentation prior to the expiration date provided on the front of the CPR card in order to attend clinical rotation.
Student Health Insurance Midway University requires students completing internships, practicums, clinical and student teaching to purchase their own health insurance and provide evidence of current coverage. Medical coverage must be in effect during all semesters of the nursing program. Copy of Medical cards are not acceptable. Proof of insurance (letter) from the insurance company must be submitted with application. The letter must include the student’s group number and effective date. Any change in medical coverage during the program must be submitted at that time. See University Catalog at https://orgsync.com/114283/files/824905/show for more information.
5 Revised 2015, 2016, 2018, 2019, 2020
TB (Tuberculosis) Status Requirement 1. Student has never received TB Complete 2-Step Tuberculin Skin Test testing OR Complete blood assay testing for either QuantiFERON®-TB Gold or T-Spot® *If either testing is positive, follow recommendations for #3 below.
2. Student has received TB testing: *less than 365 days of last Complete a single-dose TB Skin Test documented TB test OR Complete blood assay testing for either QuantiFERON®-TB Gold or T-Spot® *If either testing is positive, follow recommendations for #3 below.
*greater than 365 days of last Complete 2-Step Tuberculin Skin Test documented TB test OR Complete blood assay testing for either QuantiFERON®-TB Gold or T-Spot® *If either testing is positive, follow recommendations for #3 below.
3. Student has tested positive for TB Submission of one-time chest x-ray screening negative for TB.
Student must provide documentation of symptom screening/risk assessment performed by a healthcare provider annually thereafter.
4. Student who previously received Complete blood assay testing for either BCG (bacilli Calmette-Guérin) QuantiFERON®-TB Gold or T-Spot® vaccination
Documentation of TB must remain current (less than 365 days between testing) and with negative result of TB while in the ADN and/or BSN program.
6 Revised 2015, 2016, 2018, 2019, 2020