Nursing Candidate Application
Biographic Data:
Last Name:
First Name:
MI:
Secondary Name: Please indicate all last names utilized while enrolled in any institution of higher education.


Preferred Mailing Address: Letter of acceptance or denial will be mailed to this address (Insert Below)

Street Address:
Apartment/Unit#:
City:
State:
Zip:
Country:
Preferred Number: *Please note the email and phone number listed here will be the primary contact regarding this application.
LWC Email Address: Letter of acceptance or denial will be emailed to this address
State of Residence:
County of Residence:



Personal Data:
What is your Citizenship Status? U.S. Citizen         Other:  
Do you hold a Visa? Yes No
*If you hold a Visa, please register with International Student Office at Lindsey Wilson College.
Gender: Male Female
Date of Birth: (mm/dd/yyyy)



Ethnicity:
Which of the following best describes your race? Please mark all that apply:
Asian
Black or African-American
White
Pacific Islander
Other   Please specify:
If English is not your primary language, please list your primary language:
If English is not your primary language, please enter TOEFL iBT score:
Please note applicants to the BSN program who document English as a second language must demonstrate an overall passing standard score of 83 on the Test of English as a Foreign Language (TOEFL iBT).



Additional Information
Have you applied for financial aid? Yes No

Have you previously applied for admission to any nursing program before? Yes No

Are you transferring from another nursing program? Yes No
If yes, please enter reason:
Note: A letter of good standing from the nursing program from which the applicant is transferring must be included with the application.

Please provide information about any tests you have taken during the process of applying to a nursing program. These would include any standardized nursing admission exams such as HESI, ATI, TEAS, TSE, NLN,etc.

Are you the first generation of your family to enroll in an institution of higher education? Yes No

Have you had any US military experience? Yes No   Currently Serving? Yes No


Emergency Contact
First Name:
Last Name:
Relationship:
Phone Number:
Street Address:
City:
State:
Zip:



Background Information

Have you ever been convicted of a misdemeanor or felony? Yes No

Have you ever had any criminal convictions, certification, registration, license or clinical privileges revoked, suspended, or in any way restricted by any institution, state or locality? Yes No

If yes, please provide notification and details directly to the Chair of the Nursing Division, Dr. Marian Smith at smithm@lindsey.edu.

Kentucky State law, KRS 314.109, requires licensed/credentialed individuals report criminal convictions to the Kentucky Board of Nursing within ninety (90) days of the conviction.

Kentucky Board of Nursing Administrative Regulation 201 KAR 20:370, states that any individual applying for license/credential must report criminal convictions. LWC Nursing Division informs applicants of this regulation upon application to the program.  Questions regarding KRS 314.109 should be directed to nursing@lindsey.edu and the Kentucky Board of Nursing.

KENTUCKY BOARD OF NURSING
312 WHITTINGTON PKY, SUITE 300
LOUISVILLE KY 40222-5172
1-800-305-2042 OR 502-429-3300
http://kbn.ky.gov

Are you currently under any form of academic probation, dismissal, suspension, disqualification, etc.? Yes No
If Yes, please discuss:

Have you ever been placed on any other form of probation, dismissal, suspension, disqualification, etc. by any college or school?    Yes No
If yes, please indicate semester/year?

If Yes, please discuss resolution:



Previous Education

High School:
Address:
City:
State:
Zip:
From Date: to:
Did you graduate? Yes No
Degree:



Admission Criteria

Have you been admitted to LWC by meeting all general requirements of a regular degree seeking student? Yes No

Please note all applicants must be admitted to Lindsey Wilson College.
Please insert LWC ID:  

Please indicate if transcripts for all previous college courses have been sent to the Registrar’s Office at Lindsey Wilson College. All official transcripts must be submitted to LWC by March 1st for the application to be considered complete. Yes No
Date requested (mm/dd/yyyy)

Official transcripts must be submitted to:
LWC Registrar’s Office
210 Lindsey Wilson Street
Columbia, KY 42728

Please indicate grade, semester and year of the prerequisite courses for application to the nursing program at LWC. Prerequisite course work must be completed with achievement of a minimum of grade of “C” in each of the following courses.

Semester Year Grade Course
Human Anatomy (BIOL 2614)
Principles of Chemistry (CHEM 1104)

Writing Studies I (ENGL 1013) unless waiver requirements are met

Freshman Seminar (FYE 1001) unless waiver requirements are met

Medical Communication (HLCA 2013)

Functions & Algebra (MATH 1013) unless waiver requirements are met

Principles of Psychology (PSYC 1003)

Writing Studies II (ENGL 1023)

Fundamentals of Nutrition (NUTR 1003)


Currently enrolled (Spring 2016) prerequisite courses. Please list.
Cumulative minimum GPA: *Entrance criteria cumulative minimum GPA of 3.00


Personal Statement

Please provide a brief statement about your desire to be admitted to the nursing program:

I certify that I have carefully considered each question and that my information is true and complete to the best of my knowledge. I authorize the release of information from any agency or individuals, who may have additional information to provide that is relevant to this application. I understand that the submission of fraudulent academic or personal records for any purpose shall be cause for dismissal from the Nursing Program at LWC.

*(Legal Signature, email serves as electronic signature)