www.msjc.edu/alliedhealth Filing Period: February 1 st February 15 th Office Hours: Monday Thursday 8:00am to 5:00pm and Friday 8:00am to 12:00pm It is the student s responsibility to request and ensure that all documents are in the Nursing & Allied Health Office by the application deadline. INCOMPLETE or INACCURATE application packets will automatically disqualify the applicant. Applications must be hand delivered in person to the Nursing & Allied Health Office located on the Menifee Valley Campus, Building 500. Correspondence with students regarding application will be via MSJC student email only. Applicants must have received an Eligibility Letter to be able to apply. A copy of the Eligibility Letter and entire evaluation must be submitted with the application. Date: Last Name (Please Print) First Name Middle Name (Initial) Previous name (Please Print) Previous name (Please Print) MSJC Student ID # Email Address (MSJC Student Email Only) Mailing Address City State Zip ( ) ( ) Primary Phone # Alternate Phone # For students that have taken the TEAS: Adjusted Individual Score: Institution TEAS was taken at: ***Please submit a copy of your UNOFFICIAL TEAS scores with your application. You will be asked to submit OFFICIAL TEAS scores if you are invited to take the TEAS exam here at MSJC. Page 1 of 5
Initial (Student) Initial (Staff Confirmation) 1. Copy of Eligibility Letter and Academic Evaluation 2. Copy of Current California License: LVN, Psychiatric Technician, Radiology, Ultrasound Technician, Paramedic (Applicant must be in good standing with licensing board) and/or Copy of Current California Certificate: CNA, HHA, EMT/EMS 3. Copy of High School Diploma, GED, California Proficiency Exam, or Degree from an Accredited College or University 4. Have you ever been convicted of a felony/misdemeanor? YES NO 5. Have you ever violated the Student Code of Conduct at any College and/or University? YES NO 6. Have you ever had your License (LVN, Psychiatric Technician, Radiology, Ultrasound Technician, or Paramedic) or Certificate (CNA, HHA, or EMT/EMS) suspended or revoked? YES NO N/A ***If you marked yes to any of the above questions (4, 5, and/or 6), you must attach a one page statement explaining the incident and any supporting documentation. Marking yes, does not disqualify you from the program, but assists the program faculty to develop a strategic plan to help you be successful in the program. If you fail to submit your one page statement, your application will not be reviewed and you will be ineligible for admission consideration.*** 7. Life Experiences or Special Circumstances: A maximum of 5 points will be applied to one area only. Please mark the appropriate boxes. a. Student identified by Disabled Student Program (DSPS): (copy of Academic Accommodation paperwork must be submitted with application) b. Low Family Income: c. First generation to attend college: d. Need to work: e. Participant of EOP&S: (Copy of Educational Plan from EOP&S Counselors much be submitted with application) f. Veteran Status: (Copy of DD214 must be submitted with application) g. Military Education and Experience h. Refugee i. Difficult personal or family situation or circumstances: 8. Proficiency or Advanced Level Coursework in Languages other than English. a. Circle the language in which you are proficient: American Sign Language, Arabic, Chinese (including various dialects), Farsi, Russian, Spanish, Tagalog, Languages of Indian Subcontinent & East Asia b. Check the appropriate box that supports your proficiency in the above language: Advanced Placement Score of 3, 4 or 5 (attach scores if not verified on Transcript Evaluation) CLEP Score (attach score if not verified on Transcript Evaluation) Two (2) semesters from a U.S. regionally accredited College or University (attach transcript if not verified on Transcript Evaluation) Identified language above is spoken at place of residence. Page 2 of 5
7. Approximate Expenses: I agree to the cost of tuition, ASB, parking permit as stated in the current MSJC catalog, Nursing uniforms ($200), textbooks and supplies ($2000), CPR course ($60), Physical examination ($300) Background and Immunization Clearance ($121), Licensing Board Application ($400), ATI testing materials ($600), the Student Supply Kits ($100.00), Professional Liability Insurance ($50) and Health Insurance (cost varies). I understand the approximate expenses for participation in the Associate Degree Nursing Program and I am aware that expenses are subject to changes. Change in name/address/phone number must be submitted to the Nursing Office in writing. Your admission will be compromised if you are unable to be reached. All Students must have one of the following: Proof of High School Diploma, G.E.D., California Proficiency Exam, or a Degree from an accredited College or University. If not verified on Eligibility letter, you must submit documents with application. All Students must have a Social Security Number that qualifies for employment in the United States. I hereby give permission for Enrollment Services to share information (including transcripts, grades, and evaluation results) with MSJC s Department of Nursing and Allied Health. To the best of my knowledge, the above information is true and accurate. Failure to disclose accurate information will result in your application being removed from consideration and/or dismissal from program upon acceptance. Please sign below indicating you have read all the above statements. Student Signature: Date: **We strongly recommend that all students open their email communication from the Associate Degree Nursing Program on a desktop computer. Page 3 of 5
STUDENT DEMOGRAPHIC DATA SURVEY Semester Entering: Fall Year: 2018 Instructions: Read each statement and mark your response in the bubble. Do not provide your name. 1. Age: 25 or younger 26-30 years 31-40 years 41-50 years 51-60 years 61 years and older Age when applying to the ADN program: 2. Gender: Female Male 3. Ethnicity: American Indian Black or African American Alaska Native Hispanic or Latino Asian Native Hawaiian or Pacific Islander o Chinese White/Caucasian o Filipino Other o Japanese o Korean o Malaysians o Pakistanis o Asian Indian o Thai o Other 4. Veteran: 5. Do you have dependents (e.g., children under the age of 18, parents or grandparents) living with you? 6. Number of children living at home: ne 1 2 3 4 or more 7. Family status: Divorced Single Married Widowed Separated 8. One-way travel distance from residence to campus: 0-10 miles 11-20 miles 31-40 miles 21-30 miles 41 or more miles Page 4 of 5
9. Average weekly hours of employment: Currently not working Less than 8 hours 8 hours, but less than 16 16 hours, but less than 24 24 hours, but less than 32 32 hours, but less than 40 40 hours or more STUDENT DEMOGRAPHIC DATA SURVEY 10. Have you had previous experience in health care? (Including Military Education/Coursework) 11. Years working health care: ne Less than 1 year 1 year, but less than 3 years 3 years, but less than 6 years 6 years, but less than 9 years 9 years or more 12. Health occupations experience: ne College course: community involvement College course: paid work experience Licensed Vocational Nurse Certified Nurse Assistant Volunteer work in a health care setting Paid work experience in a health care setting Military education/coursework Other 13. Highest educational level completed: High school/ged Associate degree Bachelor s degree Master s degree or above 14. Did you move from out of state to attend this program? 15. Program prerequisite courses taken at this college: Anatomy & Physiology (ANAT 101 & 102) Freshmen Composition (ENGL 101) Intermediate Algebra (MATH 096) Microbiology (BIOL 125) t Applicable 16. Do you receive a scholarship or financial aid? Mark all that apply. Pell Grant GAIN Employer Local organization scholarship n/a 17. Are you eligible to receive a BOGG Grant through any of the following: Pell Grant, GAIN, JOBS, JTPA, SST, General Assistance, AFOC, any other form of economic public assistance, and/or annual income level below $7,500 for single person, $15,000 per couple with $1,000 additional for dependent child? Page 5 of 5