About You |
Legal Name |
|
|
|
|
Home address |
|
|
|
|
Cell phone (or primary phone number)
Example: 555-555-5555 |
Email address
|
Marital status
single
divorced
married
|
|
|
Parent(s)/guardian(s) address |
|
|
|
|
|
|
Admission Information |
Have you applied for admission to Southern?
no
yes
|
Did you indicate nursing as your major?
no
yes
|
Have you taken courses at any other college?
no
yes
|
Have you had high school Chemistry?
no
yes
|
When do you wish to begin general education courses at Southern?
|
When do you wish to begin *clinical nursing courses at Southern?
*a clinical nursing course is any in which you give direct patient care. |
|
|
Have you had any clinical nursing courses?
no
yes
|
| If yes, name courses below: |
|
|
|
|
| The school of nursing reserves the right to deny admission to or remove students from the nursing program who have records of misconduct legal or otherwise, that could jeopardize thier professional performance. |
Have you at any time ever engaged in any form of child abuse or child molestation or engaged in the use, sale, or other distribution of illicit drugs?
no
yes
|
If yes, please explain.
|
Have you ever been convicted of a crime, other than a minor traffic violation?
no
yes
|
If yes, please explain.
|
|
