Practical Nursing Application

Practical Nursing Application

Betty Owen School of Practical Nursing
This application is for the El Dorado Evening program.
Would you consider the Warren Day Program as a second alternative?

YesNo
Would you consider the El Dorado Evening Program as a second alternative?

YesNo
Date of Application*

MonthDayYearHourMinutesAM/PM Option
To be considered for admission into the South Arkansas Community College Practical Nursing Program the applicant must:
- Exhibit a South Arkansas Community College cumulative grade point average (GPA) of 2.0 or higher on a 4.0 grading scale (“C” or better).
- Complete all prerequisite nursing courses with a 2.0 or greater GPA on a 4.0 grading scale.
- Be enrolled in no more than two (2) nursing prerequisite courses during the semester immediately prior to the semester in which the student desires admission to the LPN program (example, during the summer for fall admission or during the fall for spring admission).
All remaining prerequisite nursing courses must be successfully completed by the end of the semester prior to the beginning of the professional program.

Students must complete the following:
- Meet with a nursing academic advisor or health-science career advisor.
- Complete and submit the Practical Nursing application.
- Successfully complete the TEAS, achieving acceptable scores in all areas
  - Composite - 40
  - Reading - 45
  - Math - No minimum required
  - Science - No minimum required
  - English - No minimum required
I have read the requirements for being considered for the nursing program and understand that I will not be eligible if these requirements are not met.*

Yes

Admission Application

Please answer all questions to the best of your ability. All areas should be completed. Any blank areas are concidered incomplete and the applicant will not be eligible for admission.

Applicant's Full Name*

First NameLast Name
Email Address*
Social Security Number*
Date of Birth*

MonthDayYear
Student ID*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Mobile Phone Number*

Area CodePhone Number

Place of Employment
Work Phone Number

Area CodePhone Number
Place of Employment
Family Physician*
Emergency Contact*
Relationship to Student*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Phone Number*

Area CodePhone Number

Educational History

Please provide all institutions of higher learning (Colleges or Universities) you are currently or have previously attended.
Institution Name*
Location*
From*

MonthDayYear
To*

MonthDayYear
Total Credit Hours earned from this institution.*
Institution Name
Location
From

MonthDayYear
To

MonthDayYear
Total Credit Hours eaned from this institution
Location
From

MonthDayYear
To

MonthDayYear
Total Credit Hours earned from this institution

Are you Currently Enrolled in any college courses?*

YesNo

You answered yes to the previous question. Please provide the course name(s) and the credit hours for the course(s) you are currently enrolled in.
Course Name*
Number of credit hours *
Course Name
Number of credit hours
Course Name
Number of credit hours
Course Name
Number of credit hours
Course Name
Number of credit hours

Have you ever been admitted into a SouthArk Practical Nursing Program?*

YesNo

You answered yes to the previous question. Please answer the next 2 questions.
Year of Admission:
What was the reason for withdrawal?*

Employment

Include all employment within the past five years beginning with the most recent. Please fill out completely.
Employer # 1
City, State
Job Responsibilities
From

MonthDayYear
To

MonthDayYear
Reason for Leaving
Employer # 2
City, State
Job Responsibilities
Date Began Employment

MonthDayYear
Date Employment Ended

MonthDayYear
Reason for Leaving
Employer # 3
City, State
Job Responsibilities
Date Employment Started

MonthDayYear
Date Employment Ended

MonthDayYear
Reason for Leaving

Background
Have you ever been convicted of a felony? (This includes expunged and /or sealed records and juvenile offenses)*

YesNo

You answered yes to the previous question. Please explain.
Explanation:*

Have you ever been convicted of a misdemeanor? (This includes expunged and /or sealed records and juvenile offenses)*

YesNo

You answered yes to the previous question. Please explain.
Explanation:*

Have you ever been convicted of child maltreatment?*

YesNo

You answered yes to the previous question. Please explain.
Explanation:*

Have you ever held a license of certification that has been disciplined?*

YesNo

You answered yes to the previous question. Please explain.
Explanation:*

Personal Statement
Please explain why you are seeking admission into the practical nursing program. Include any information that you feel would assist in your selection to the program.*
I hereby certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or falsification of information is reason for denial of admission to the Health Sciences Program.
Application Accuracy Electronic Signature:

First NameLast Name

MENTAL AND PHYSICAL ABILITIES STATEMENT

You should be aware of the mental and physical abilities required in nursing education. These same abilities will likely be needed for a successful professional career.
1. Working in a standing position and walking for extended periods of time.
1. Lifting and transferring patients up to 6 inches from a bending position, then pushing/ pulling/pivoting weight up to 3 feet.
1. Lifting and transferring patients to accomplish bed-to-chair and chair-to-bed transfers.
1. Applying up to 10 pounds of pressure to bleeding sites and in performing CPR.
1. Responding and reacting immediately to auditory instruction, requesting, and/or monitoring equipment, performing auscultation without auditory impairment.
1. Performing up to twelve hours in a clinical laboratory setting.
1. Observe patient response/condition: distinguish color and color intensity; prepare medication; see graphs, computer screens, read written documents, policies and protocols.
1. Discriminating between sharp/dull and hot/cold when using hands.
1. Performing mathematical calculations for medication preparation/administration.
1. Communicating effectively, both orally and in writing, using appropriate grammar and vocabulary.
1. Reacting appropriately and professionally under stressful situations.
1. Be able to critically think and use therapeutic nursing judgment; be able to recall nursing theory (i.e., safety, disease processes, medication administration, and client management).
I have read the mental and physical abilities statement and believe that I can successfully complete the tasks listed above. It is my responsibility to inform SouthArk’s Nursing Program Director and Clinical Instructor if any of the above changes during my enrollment in the Betty Owen School of Practical Nursing Program.
Mental and Physcial Abilitites Statement Electronic Signature

First NameLast Name

Should be Empty:

Practical Nursing Application

Admission Application

Educational History

Employment

Background

Personal Statement

Statistical Information