ADN Application - Midway College

MIDWAY COLLEGE
ADN PROGRAM
NURSING APPLICATION
We are pleased that you are considering the Midway College ADN Program. Midway is accredited by the
Accreditation Commission for Education in Nursing, Inc. (formerly National League for Nursing Accrediting
Commission), 3343 Peachtree Rd., Suite 850, Atlanta, Georgia 30326, Phone: 404-975-5000, Fax: 404-975-5020,
www.acenursing.org and has full approval of Kentucky Board of Nursing, 312 Whittington Pkwy., Suite 300, Louisville,
KY 40222, Phone. 502-429-3300, Fax. 502-429-3311, http://kbn.ky.gov.
The following application form should be filled out completely and accurately. All information is kept
confidential and is used for the nursing Program Evaluation process only. This information will not be released to any
other entities within or outside of the college unless a written consent is given by you, the applicant.
Please return pages 3, 4 and 5 and retain the remaining pages for your records. Please mail the application and
recommendation letters to:
Midway College
ADN Nursing Program
512 East Stephens Street
Midway, KY 40347
NOTICE OF NON-DISCRIMINATION
Midway College does not discriminate on the basis of race, color, religion, national or ethnic origin, marital
status, age, or disability in administration of its educational policies, admissions policies, scholarship and loan programs,
and athletic and other College-administered programs or in its employment practices. In conformity with Title IX of the
Education Amendments of 1972, 20 U.S.C. § 1681 and its implementing regulation at C.F.R. Part 106, it is also the
policy of Midway College not to discriminate on the basis of sex in its educational programs, activities or employment
practices. The admission of women only in the Traditional Day Programs is in conformity with a provision of the Act.
For additional information, contact the College‘s Title IX Coordinator: Ann Elkin, Director of Human Resources, 11
Pinkerton Hall, 512 East Stephens Street, Midway, Kentucky 40347-1112, (859) 846-5408.
Midway College is committed to providing an environment that is safe and provides appropriate motivation to
insure a creative and productive work force and academic setting. To this end, Midway College endorses the philosophy
that the campus should be free from the detrimental effects of drugs and alcohol. To insure student and worker safety and
workplace and classroom integrity, Midway College prohibits the illegal manufacture, possession, distribution, or use of
alcohol, controlled substances, and illicit drugs on its campus or as part of any of its activities. Further, except for
employees and guests living in private residences of the college or college residences leased for private use, by authority
of the Board of Trustees, possession and use of alcoholic beverages on the campus by employees, students, or guests is
prohibited. The Midway College Alcohol Policy approved in 2003 limits the serving of alcohol only as approved by the
college president.
Retain for your records
Effective fall 2011, all applicants seeking admission into the Midway College ADN program must complete an approved
Kentucky Medicaid Nurse Aide training course. After completion of the course, applicants must then take and pass the State
of Kentucky Medicaid Nurse Aide exam (SRNA). Proof of SRNA must be submitted to the Nursing Office. A copy of the
course completion certificate is not sufficient documentation. The SRNA is part of the admissions criteria.
Approved Nurse Aide Training Providers
Contact: Vicki Barber, RN, NCI
Cabinet for Health and Family Services
Department for Medicaid Services
Division of Healthcare Facilities Management
Long Term Care Branch
275 East Main Street, 6 C-B
Frankfort, KY 40601
(502) 564-5707
Email: [email protected]
Bluegrass Community & Technical College
Nurse Aide Training
164 Opportunity Way
Lexington, KY 40511
859-246-6642
www.bluegrass.kctcs.edu/nursing/nursing_aide
Campbellsville University-Hodgenville
813 Old Elizabethtown Road
Hodgenville, KY 42748
270-789-54004
www.campbellsville.edu/srna1
Gateway Community & Technical College
500 Technology Way
Florence, KY 41042
859-441-4500
www.gateway.kctcs.edu/academics/programs_of
_study/mna
Health Education Center, LLC
10508 Nanka Road
Louisville, KY 40272
502-510-1363
www.healtheducationcenter.us
KY Health Training
343 Waller Avenue, #204
Lexington, KY 40504
859-963-2901
www.khtnow.com
Red Cross Nurse Aid Training
510 E. Chestnut Street
PO Box 1675
Louisville, KY 40202
502-561-3771
www.redcross.org/ky/louisville/nat
St. Catharine College
237 N. Spalding Avenue, Suite #108
Lebanon, KY 40033
270-699-2157
www.sccky.edu/academics/continuingcommunity-ed.php
Revised Spring 2015
Bluegrass Nurse Aid Training Center
304 Southland Drive
Lexington, KY 40503
859-273-0068
www.bgnurseaide.com
Campbellsville University
1 University Drive
Campbellsville, KY 42718
270-789-5400
www.campbellsville.edu/srna
Emergency Medical Training
Professionals, LLC
1141 Red Mile Road, Suite 101
Lexington, KY 40504
859-327-3687
www.emtpky.com/srna
Georgetown Nurse Aide Training
804 S. Broadway, Suite #1
Georgetown, KY 40324
502-867-7283
www.khtnow.com
Enrich Me Learning Center
96 Court Square
Bardstown, KY 40004
502-349-1500
Kentucky Community & Technical
College System
(search by school)
www.kctcs.edu
Kentucky Health Care Training Institute
7400 New LaGrange Road, Suite #103
Louisville, KY 40222
502-426-3338
www.healthcareky.com
Nurse Aide Training School, Inc.
370 Highland Park Drive, Suite 1-B
Richmond, KY 40475
859-624-4068
www.natcrichmond.com
Medical Career and Technical College
630 Eastern Bypass
Richmond, KY 40475
859-624-1988
Spencerian College
1575 Winchester Road
Lexington, KY 40505
859-223-9608
www.spencerian.edu
Wisdom & Health Institution
3920 Bardstown Road, Second Floor
Louisville, KY 40218
502-491-0492
www.wisdomandhealthinstitution.com
2
Healthcare Training School
Bardstown, KY
502-507-3497
Spencerian College
4627 Dixie Highway
Louisville, KY 40216
502-447-1000
www.spencerian.edu
Rev9/2013, 2/2014
Kentucky Board of Nursing Policy
on Requirements for
Licensure Applicants with Criminal Convictions
State law requires that licensed individuals report criminal convictions to the Kentucky Board of Nursing
within ninety (90) days of the conviction, KRS 314.109. Kentucky Board of Nursing Administrative
Regulations 201 KAR 20:370, application for licensure and registration, also require applicants to report
criminal convictions and states what must be submitted when reported.
I have read the Kentucky Board of Nursing Policy on the Requirements for Licensure Applicants with Criminal Convictions
and understand these requirements.
I also understand that individuals who have a felony conviction are not eligible for placement in clinical courses and so
cannot be admitted.
Signature
Date
Kentucky Board of Nursing
312 Whittington Pkwy., Suite 300
Louisville, KY 40222-5172
1-800-305-2042 or 502-429-3300, Ext. 238 or 243
http://kbn.ky.gov
Revised Spring 2015
3
Midway College
ADN Nursing Application
_____Day Track
_____ Evening Track
NAME:
(Last)
(First)
(Middle)
(Maiden Name)
ADDRESS:
(Street or P.O. Box)
(City)
(State)
(Apartment #)
(Zip)
(Cell ph. #)
(Home ph. #)
MIDWAY EMAIL ADDRESS: _________________________________________________________
OTHER EMAIL ADDRESS: __________________________________________________
Birthdate:
/
/_____
Student ID #:
Social Security #:
Please identify your ethnic background. Although this information is voluntary, it is requested to fulfill
reporting obligations of the College. Information will be confidential.
Native American
African American/Black
Asian/Pacific
Hispanic
Caucasian/White
Non-Resident Alien
Other
Have you been accepted by Midway College? __ yes __ no
Residential:
Have you previously interviewed for the Nursing Program at Midway?
When? ___________________________
Commuter:
____ yes ____ no
SRNA ___ yes ____ no License number: ____________________________
Currently taking classes at Midway? __ yes __ no __ full-time __ part-time Cum. GPA: ______
Are you transferring from another college?
(Where)
(GPA)
Colleges attended (Begin with the most recent.)
Name and location of institution
Dates of attendance
Revised Spring 2015
4
Major/Degree(s) earned
Have you ever been enrolled in a health sciences program which you did not complete?
_____ yes _____ no
Have you been enrolled in a nursing program in the past? If yes, a letter of explanation must be attached and
page 7 must be completed and sent to the former program to be completed.
_____ yes
_____ no
All required immunizations and health certifications must be submitted with the nursing application.
Please see page 6 for details.
Are you currently employed?
(Where)
(Phone #)
List work experiences:
_________
Have you ever been convicted of a crime? _____ yes
If yes, a letter of explanation must be attached.
_____ no
Three letters of recommendation are required. These letters should be from professionals (ex.
supervisors, teachers or ministers) and should address your character and personality. Letters
can be included with the application or mailed separately.
1.
2.
3.
I have read and understood all the above questions. My answers to these questions are true to the best of
my knowledge.
(Applicant’s Signature)
Revised Spring 2015
(Date)
5
IMMUNIZATIONS & HEALTH CERTIFICATIONS
All required immunizations, certifications, and other items listed below are to be submitted to the Nursing Office for
students entering NSG 115, transfer students, or returning students. No student will be allowed to attend clinical
rotations until these requirements are met and appropriate documentation is on file in the Nursing Office. The clinical
absence policy is within the ADN Student Handbook, which each student receives at the beginning of the NSG 115
course.
MMR (Measles (Rubeola), Mumps, and Rubella)
1. Official immunization record containing 2 documented MMR vaccination dates or;
2. Titer results showing positive immunity for each component of MMR
Varicella (Chicken Pox)
1. Official immunization record containing 2 documented varicella vaccination dates or;
2. Titer results showing positive immunity for varicella
-- Students may be required to provide titer results showing immunity to varicella before attending clinical
rotations at particular facilities. These students will be notified at the time of clinical assignment, if
documentation of a titer is not already on file.
Hepatitis B
1. Official immunization record containing dates of all vaccinations or;
2. Titer results showing positive immunity for Hepatitis B Surface Antibody or;
3. If a student does not wish to obtain the Hepatitis B vaccine or is not complete with the series, the
Hepatitis B Waiver form should be signed and placed in the student’s file. The form is available in the
Nursing
Office. Should the student complete the vaccine series or obtain a titer, it is the student’s responsibility to
submit documentation to the Nursing Office.
TB skin test or T-Spot test
1. Students must retest and submit documentation annually.
2. Students testing positive for TB the first-time should be re-evaluated by chest x-ray and submit results.
Documentation of symptom screening for TB performed by a primary healthcare provider must be
submitted
annually thereafter.
CPR
1.
2.
3.
Infant, Child, and Adult Resuscitation are required for certification.
Acceptable certifications:
American Heart Association (preferred) = Basic Life Support for the Healthcare Provider
American Red Cross = Professional Rescuers and Healthcare Providers
-- Many certifications completed through an online format are not acceptable (i.e., ProCPR, ASHI, HIS).
Please
call the Nursing Office with questions.
It is the student’s responsibility to recertify and submit documentation prior to the expiration date provided on
the front of the CPR card.
Influenza Vaccination
Most clinical sites, contracted with Midway College’s ADN program, require employees and students to provide
documentation of influenza vaccination during the flu season. Any deferments would need to be approved by the
contracted site. Those who are not vaccinated will be required to wear a mask while on the unit during flu
season. A copy of the vaccination should be provided to the Nursing Office.
Student Health Insurance
Midway College requires students registering for internships, practicums, clinical and student teaching to purchase
their own health insurance and provide evidence of current insurance card. A copy of the insurance card must be
submitted to the Nursing Office prior to attending clinical rotation. See College Catalog at
http://www.midway.edu/academic-programs/college-catalog for more information.
Revised Spring 2015
6
Midway College
Associate Degree Nursing Program
Applicant Information Form
Name:
School Name:
ID Number:
Telephone:
Date enrolled:
__________/__________
Month
Year
to
__________/__________
Month
Year
I request that the following information be provided to the Midway College Associate Degree
Nursing program. I do/do not (circle one) waive my right under the Buckley Amendment to inspect
this reference which will be filed in my student record.
_________________________________________
Signature
____________________________
Date
To be completed by the nursing program director:
The above student has applied for admission to the Associate Degree Nursing program at Midway
College and requested the following information be provided to Midway.
Was the student’s performance satisfactory in all areas while in your program? _____ yes
no
_____
If no, please indicate any deficiencies by checking the appropriate category(ies) below.
_____
_____
_____
_____
Nursing theory grade below passing.
Clinical performance unsatisfactory.
Withdrew from course(s) in which performance was deficient at the time of withdrawal.
Other (Please describe). ____________________________________________________
________________________________________________________________________________
Did this student apply for readmission to your program?
_____ yes
_____no
Is this student eligible for readmission to your program?
_____ yes
_____ no
If not eligible for readmission, please list reason(s): ____________________________________
______________________________________________________________________________
Please comment on your opinion of the applicant’s potential for success:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
__________________________________________
Signature
_______________________
Date
Please return this form to: Midway College, Nursing Department, 512 East Stephens Street,
Midway, Kentucky 40347
Revised Spring 2015
7

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