ADVANCED PLACEMENT ASSOCIATE DEGREE LVN TO RN PROGRAM APPLICATION
June 2024
^
The information noted with this symbol will in no way affect your ability to enter the Nursing and Allied Health Programs; it is obtained for statistical purposes ONLY. It will be kept confidential and used to gather data needed to receive state and federal funding.
APPLICANT INFORMATION
Full Name
*
First Name
Last Name
Middle Name
*
Previous Name(s)
First Name
Last Name
MyCuesta Email Address
*
Confirmation Email
This MUST be your @my.cuesta.edu address. Example: cougar_green@my.cuesta.edu
Personal Email Address
*
Confirmation Email
Confirm Email
Cuesta Student ID Number
*
Primary Phone Number
*
Secondary Phone Number
Current Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is your current address the same as your permanent Address?
*
Please Select
Yes
No
Permanent Address
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Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth^
*
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Month
/
Day
Year
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Age at time of application^
*
Gender^
Please Select
Female
Male
Other/Decline to State
California Residency^
*
Please Select
Yes
No
If yes, how many years?
Race/Ethnicity^
*
Please Select
American Indian (All persons descended from the original peoples of North America)
Asian (Persons having origins in the Far East, Southeast Asia, the Indian Subcontinent; including for example: Cambodia, China, Indonesia, Japan, Korea, Laos, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)
Other Asian (Asian, other than Chinese, Filipino, Japanese, Korean, Malaysian, Pakistani, Asian Indian, or Thai)
Black (All persons having origins in any of the black racial groups of Africa and not Hispanic in origin)
Hispanic (All persons of Chicano, Mexican, Puerto Rican, Cuban, Central/South American, or other Spanish culture origin regardless of race)
Native Hawaiian or Other Pacific Islander
White (All persons having origins in Europe, North Africa or the Middle East and not of Hispanic origin)
Other not listed
Primary language spoken at home^
*
Please Select
American Sign Language
Arabic
Chinese
English
Farsi
Languages of Indian Subcontinent and Southeast Asia
Russian
Spanish
Tagalog
Other
Are you a veteran?^
*
Please Select
Yes
No
Are you the spouse of a veteran?^
*
Please Select
Yes
No
Have you applied to the Cuesta RN Program before?^
*
Please Select
Yes
No
If yes, what year(s) did you apply?
Have you ever been admitted to an RN Program before?^
*
Please Select
Yes
No
If yes, please enter the names of the programs you have attended
1. ACADEMIC DEGREE OR RELEVANT CERTIFICATE
Education
Please Select
Master's Degree or Higher
Bachelor’s Degree
Associate’s Degree
Licensed Health Care Worker
Indicate your highest level of education obtained by the application deadline
College/University Attended - Other than Cuesta College
School
City
State
Dates Attended
1.
2.
3.
4.
5.
2.
PREREQUISITE COURSEWORK & MATH
*Online and Distance Education labs are not accepted. Exception- Online labs accepted Spring 2020- Spring 2022 only.
School
Course #
Term/Yr
Credits
Grade
Microbiology with lab* (Bio 204)
Human Anatomy with lab* (Bio 205)
Human Physiology with lab* (Bio 206)
English Composition (Eng 201A)
Math Competency (Math 127 or Higher)
2a.
REPEATS IN SCIENCE AND ENGLISH PREREQUISITE COURSES
For the LVN to RN program, there is no penalty for repeats.
Repeat includes the following grades of C-, D, F, I, NP, W, FW. Please indicate the number of course repeat(s):
Number of Repeats
Human Anatomy with Lab
0
1
2
3
Human Physiology with Lab
0
1
2
3
Microbiology with Lab
0
1
2
3
English Composition
0
1
2
3
Repeat Total:
3. CALIFORNIA LVN LICENSE & WORK EXPERIENCE
Upload required documentation below
California LVN License
*
Upload a File
Cancel
of
Work Experience Verification Form
*
Upload a File
Verification of a minimum of six months work experience as an LVN, within the past two years
Cancel
of
Professional Resume
*
Upload a File
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of
Employer Letter(s) (OPTIONAL)
Upload a File
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of
APPLICANT ACKNOWLEDGMENT AND AGREEMENT
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