Rappahannock Community College

Application: Associate in Applied Science, ADN Program

For Entry in Fall of ______(Year)

READ CAREFULLY: Per VCCS Policy 6.0.5, admission consideration is given to qualified applicants who are

residents of the political subdivisions supporting the College and residents of those localities. Since enrollments are

restricted for the Nursing Program, admission consideration will be given to residents of the RCC service area first.

Contact your nursing advisor for questions.______Initials

APPLICANT INFORMATION
Last Name / First Name / MI / Date
Physical Street Address / Apt #
City / County / State / Zip
Mailing Address / Apt #
City / County / State / Zip
Home Phone / Work Phone / Cellular Phone
VCCS Email address / Alternate Email Address
VCCS Student ID / Have you ever applied to this program before? No______Yes______
If yes, when?
Campus Choice: ______Warsaw ______Glenns
Note: Students may choose one home campus, but must be flexible in the event that course and clinical scheduling dictates a change in campus location. Similarly, space may be available in courses or clinical sites at or near the opposite campus necessitating faculty placement there. Campus locations are honored as your first choice, but not guaranteed. ______Initial that you have read and understood this statement.

Please list all of your academic history in the spaces below and include any and all degrees or certificates earned.

ACADEMIC HISTORY / FROM / TO / Last year attended / GRAD
(Y/N) / Degree if applicable
Currently in High School
Name of HS:
High School graduate
Name of HS:
GED Completion
Vocational School Name
College Name
College Name
College Name
Have you ever enrolled in a nursing fundamentals course at either the ADN or LPN level? ______Yes ______No.
If yes, what school and what year?

If you are applying under the Guaranteed Admission Provisions, sign here______

Training/Certificates / Y/N / Currently Practicing / Last Date of Practice / License or Certificate #
Certified Nursing Assistant / ____Yes ____No
Certified Medication Aide / ____Yes ____No
EMT Basic / ____Yes ____No
EMT Intermediate / ____Yes ____No
Paramedic / ____Yes ____No
AHA BLS for HealthCare Provider / ____Yes ____No
Cardiac Technician / ____Yes ____No
LPN/LVN / ____Yes ____No
CHECKLIST FOR COMPLETE APPLICATION / INITIALS
I am enrolled as a student at Rappahannock Community College. If separated from RCC for more than 3 years, a new college application is required.
I have completed all required college testing (VPT MTH & ENG) and developmental course work, if applicable.
I have attended a general information session and have met with my nursing program advisor. (Strongly encouraged). If yes, initial in space. If no, state NO.
All official transcripts from each college I have attended have been hand delivered by me in sealed envelopes to College Counseling or mailed directly by my college to Admission and Records. RCC transcripts do not need to be official.
I have been curriculum placed by College Counseling.
I have completed the ATI TEAS Pre-Nursing Entrance Test within the last 3 years and it is included with this application. My score is above the 45th National Percentile Rank. Required for traditional application, strongly recommended for Guaranteed Admissions.
I have a cumulative GPA of 2.0 in all coursework.
If applying under Guaranteed Admissions, I have a 3.0 in all curricular courses.
I have completed all pre-application requirements listed in the application package
I certify that I do not have any conduct violations from RCC or any other college attended and/or I understand that the Admissions Committee will verify
I certify I have had one unit of HS BIO and CHM with a grade of “C” or higher or the college equivalent (1 semester of each)
READ ONLY: Criminal Background Check Statement—A criminal background check and drug screen are required for admission to the Nursing Program as required by our clinical affiliates. If you have a criminal conviction you should contact www.certifiedbackgound.com to determine if your conviction will prevent you from enrolling in this program. Initial______
READ ONLY: Student Accommodations Statement---The Nursing Program is committed to the policies set forth by RCC regarding disabilities and reasonable accommodations. If you require special services or accommodations, you should contact the RCC Disability Services Counselor on either campus for an appointment at least 2 weeks prior to the beginning of classes if you are accepted into the Nursing Program. Your success is contingent upon your ability to fulfill the core competencies of the program. Initial______

IMPORTANT NOTE: All prospective students are required to be eligible to participate in all clinical facilities where we are contracted to provide clinical supervision. Students who are not eligible for rehire or in good standing in any facility may be prevented from clinical experiences, and thus may forfeit their seats in the nursing program. Please complete the following:

I am a current employee, in good standing, in a healthcare facility in the following systems: Sentara, Riverside, Bon Secours or Mary Washington. / Yes / No / If yes, what facility?
I am a former employee in a healthcare facility from the above listed systems / Yes / No / If yes, what facilities? List all
As a former employee, I left in good standing and am eligible for rehire. / Yes / No / If you are unsure, you MUST contact your former employer for verification

Guaranteed Admission Provisions

Students applying under the Guaranteed Admission Provisions, in addition to meeting the above requirements for the ADN program, must:

·  Have completed all of the courses or equivalents listed below AND the general High School requirements with a grade of “C” or better (CHM and BIO). BIO can be taken as part of the CSC in Pre-Nursing. If you have not had HS CHM, you should take that in addition to completing the remainder of the courses in the CSC in Pre-Nursing Curriculum.

·  Have a curricular GPA of 3.0 in these courses

·  No grade lower than a “C” in any of these courses

·  Certified as a CNA by the Virginia Board of Nursing and have an unencumbered license to practice as a CNA with a copy of the license attached.

Proceed to the Guaranteed Admission Curricular Grid on the next page.

Complete the following grid to determine your curricular eligibility.

Formula for Curricular GPA: Multiply each Academic Credit earned in Column B by its corresponding GPA points in Column D. Put this number in Column E. Add all of the earned academic credits and put the total at the bottom of Column B. Add all of the Total Curricular Points together and put at the bottom of Column E. Divide the Total Curricular points by the Total Academic Credits for the Curricular GPA.

Column A:
Course / Column B:
Academic
Credits / Column C:
Grade: Put in the grade you earned for this course / Column D.
GPA points: Enter the number of points for the grade you earned in the course
A= 4 pts
B= 3 pts
C = 2 pts
D = 1 pt
F = 0 pt / Column E.
Total Curricular Points: Multiply the Academic credits in column B with the corresponding points listed in Column C and add the total curricular points for each course below.
EXAMPLE: BIO 141 / 4 / B / 3 / 12
SDV 101 / 1
ENG 111 / 3
MTH 126 / 2
BIO 101 OR BIO 141 / 4
PSY 200 / 3
NUR 27 (If you did not take these courses in the VCCS, leave blank and don’t include in the total Academic Credits below) / 3
PSY 230 / 3
BIO 141 OR BIO 142 / 4
HLT 230 / 3
NUR 29 (If you did not take these courses in the VCCS, leave blank and don’t include in the total Academic Credits below) / 3
Total Academic Credits earned (Add all in Column B)
Total Curricular Points earned (Add all in Column E)
Divide Total Curricular Points by the Total Academic Credits for the Curricular GPA
I certify under penalty of disciplinary action up to and including automatic withdrawal from the nursing program, that all of the information is complete and accurate. I agree to supply the nursing program with supporting documentation related to my application, if I am requested to do so. I further understand that submission of this application does not guarantee admission to the ADN program.
Signature Date

RCC ADN Application Information Package, Revised January 2015Page 1