Application for Admission to Nursing and Allied Health Programs Program Applying For: *ASN (RN)Cardiopulmonary Care ScienceECG TechnicianLPN-ASNMedical Lab TechnicianNurse AssistantPatient Care TechnicianPhlebotomyPractical NursingSurgical Technology (AAS)NameFletcher Student ID *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodePrimary Phone Number *Secondary Phone NumberSchool Email AddressPersonal Email AddressDate of Birth *Did you earn your High School Diploma or HiSET (Formerly GED)YesNoAre you presently a student at Fletcher?YesNo*If you are not enrolled as a Fletcher Student the semester prior to your anticipated enrollment in ANY clinical program (excluding Summers), you must apply to the College and complete the Admissions Process.Do you currently possess a license in a healthcare profession (Ex.: EMT, LPN, etc.)? *YesNoIf yes, which license(s) do you currently possess?Have you ever been admitted to a Nursing/Allied Health Program? *YesNoWhich program were you enrolled in?What is the name of the school you attended?Why did you leave?If you did not complete the program, are you eligible for readmission to that program?YesNoIf no, why?Do you have any serious health conditions or other limitations which may prevent you from performing the tasks of the program you are interested in?YesNoIf yes, please explain:List all Colleges or Universities attended since High School, including Fletcher. You can list up to four schools. Please include Name of College, City/State, Dates Attended, and Degree/Certificate earned.Have you ever been convicted of a felony?YesNoIf yes, you are not eligible for admission into a Nursing or Allied Health program. Note: If you are applying to the Nurse Assistant program, you can not have been convicted of a violent crime.Will you be able to provide your own transportation to clinical sites?YesNoIf no, how do you plan to get there?Is there any facility that you are on a "Do Not Hire" list? List them below.Test scores - Compass/ACT/Accuplacer *Choose FileNo file chosenDelete uploaded fileTest Scores - HESI-A2 *Choose FileNo file chosenDelete uploaded fileTest Scores - HESI-A2 - Second TestChoose FileNo file chosenDelete uploaded fileHigh School Diploma or GED/HiSET Transcripts *Choose FileNo file chosenDelete uploaded fileProof of Immunizations *Choose FileNo file chosenDelete uploaded fileLegal Documents - Driver's License and Birth Certificate *Choose FileNo file chosenDelete uploaded fileWork Experience and Licensure *Choose FileNo file chosenDelete uploaded fileEssay (200 words minimum): *Choose FileNo file chosenDelete uploaded filePlease Click Here to submit a background check. Select Fletcher Technical Community College under Schools. Click on Demographics. The price is $35 and the results will be mailed directly to the Department of Nursing and Allied Health.Verification and Electronic Signature:I certify that the information given above is accurate and true to the best of my knowledge. I understand that falsification of this information and any attached documentation may result in denial of my application, denial of permission to progress in clinical nursing courses, dismissal, and/or denial of licensure. I also certify that I have read and fully understand the entire content of this application, the program's current admission guide, and the requirements of the program admission policy as stated in the College catalog. Fletcher Technical Community College does not discriminate on the basis of race, color, national origin, gender, gender identity, age, religion, qualified disability, marital status, veteran's status, or sexual orientation in its hiring or employment practices or in admission to its programs, services, or activities, in access to them, in treatment of individuals, or in any aspect of its operations.Your Signature (Type Name): *Date: *SubmitPlease do not fill in this field.