Associate Degree Nursing Application

Prospective students must have on file, official high school transcripts and, if applicable, evaluated college transcripts. Students must also be in the process of completing their final admission requirements prior to submitting this application.

Please print this application and visit our College and Career Success Center to have it verified before return the signed form to: Department of Nursing, South Suburban College, 15800 S. State Street Room 4120 South Holland, IL 60473.

Application Term 202X*

Email Address*

example@example.com

Last Name*

First*

M.I

College ID #*

Daytime Phone*

Address*

City*

State*

Zip*

Are you a Certified Nurse Assistant?*

YesNo

If yes, in which state?*

Verification of State Certification must be attached to your printed application.

Are you a Licensed Practical Nurse?*

YesNo

License #*

Verification of State Certification must be attached to your printed application.

State*

Name*

Phone Number*

Email Address*

example@example.com

Relationship*

Applicant must take this application to an academic advisor in the College & Career Success Center to be completed and signed. After that the application must be returned to the Nursing office before May 15th. Student must also attach a copy of current class schedule for verification of course enrollment along with a copy of any State certification or license to their printed application form.

I understand that, if enrolled in the Department of Nursing at South SuburbanCollege, I will be accountable for the following:

A. Transportation to and from the College and various clinical sites
B. Payment of tuition, student, laboratory and malpractice fees,uniforms, books and equipment
C. Proof of health insurance coverage
D. Submission of a completed physical examination form provided by the SSC Departmentof Nursing (including TITERS and TB test) and/or clinical affiliates.
E. Flu Vaccine is required/Covid vaccination is required.
F. Current CPR card (Must be American Heart Association) BLS for Healthcare Provider(CPR and AED) program.
G. Drug Screening and Criminal Background Check.

All expenses are the responsibility of the student.

IMPORTANT Information RELATED TO STATE LICENSURE

Upon successful completion of the program, the student is prepared to take the NationalCouncil of Licensure Examination (NCLEX-RN). The curriculum of the Associate DegreeNursing program meets the academic requirement for Illinois Department of Financial &Professional Regulation (IDFPR) and Indiana State Board of Nursing which grantslicensure to nurses through an application and examination process. Applicant mayvisit IDFRP at https://idfpr.illinois.gov or https://www.in.gov/pla/professions/nursing-home/ for more information.

I declare that I have examined the application and all required documents submitted by me are to the best of my knowledge, true, complete, and correct. Submission of this completed application to the Nursing Department does not guarantee admission to the program.

ASSOCIATE DEGREE NURSING APPLICATION (ADN)

Contact Person Other Than Self

RESPONSIBILITIES AS A NURSING STUDENT