http://www.uscb.edu/uploads/NursingApplication_BSN_21108_1

UNIVERSITY OF SOUTH CAROLINA BEAUFORT DEPARTMENT OF NURSING BACCALAUREATE DEGREE PROGRAM APPLICATION FOR ADMISSION TO THE BSN MAJOR: 4 YEAR TRACK Date _____________________, 20 __________ 1. NAME_____________________________________________________________________________________ Last

First

Middle

2. THE NAMES UNDER WHICH YOUR RECORD MAY BE LISTED________________________________ 3. PERMANENT ADDRESS_____________________________________________________________________ Street City

State

Zip Code

County_________________________________________________________ 4. TELEPHONE NUMBER (Home) _________ _________________

(Work) ________ ________________

Area Code

Area Code

(Cell #)_________ _________________

(Fax) ________ ________________

Area Code

Area Code

5. E-MAIL ADRESS ___________________________________________________________________________ 6. SOCIAL SECURITY NUMBER ____________________ 7. DATE OF BIRTH ____________________

GENDER: F___ M___

Month/Day/Year

8. ARE YOU CURRENTLY ENROLLED AT USC Beaufort? □ Yes □ No Note: Nursing students must first be admitted to the University before being admitted to the Nursing Department. If the answer is no, please do the following: a. Request that official transcripts from all previous colleges be sent to USC-BEAUFORT Office of Admissions. b. Submit application to USC-BEAUFORT (This can also be done online at www.USCB.edu.) c. If at a USC campus other than USC-BEAUFORT, submit change in campus form (check with Student Services).

(If yes) DATE OF LAST ENROLLMENT AT USC-BEAUFORT______________________________________ 9. EDUCATIONAL PREPARATION List colleges or universities attended for credit and enclose all unofficial transcripts1 Name of Institution

1

City and State

Date of Date of Entrance Leaving

Currently Enrolled

Degree or Diploma

USCB students must enclose a copy of your VIP record of Academic Work for Advisement Only (printer friendly version).

a. List courses you are presently taking (indicate course and name of college or university).

b. When do you plan on completing any remaining prerequisites? ________________________________________ (Semester)

(Year)

c. List prerequisite courses needed

10. WHEN DO YOU ANTICIPATE BEGINNING THE NURSING COURSES? January _____________________ (If the class is full, you will be placed on the waiting list for the next class) (Year) 11.

DO YOU HAVE A CURRENT LPN LICENSE? (If yes)

State ________________

□ Yes

□ No

Date of Expiration ________________

12. ON THE ATTACHED FORM (ATTACHMENT A) PLEASE DESCRIBE THE NATURE AND DURATION OF ANY HEALTH CARE RELATED EXPERIENCE IN WHICH YOU HAVE PARTICIPATED. THE EXPERIENCE MAY INVOLVE A PAID JOB OR VOLUNTEER WORK. 13. ON THE ATTACHED FORM (ATTACHMENT B) PLEASE COMPLETE A STATEMENT OF INTENT ABOUT YOUR REASONS FOR PURSUING BACCALAUREATE NURSING EDUCATION. 14. Please provide two written references that address your potential as a nurse. The reference forms can be downloaded from the USCB website (www.USCB.edu) ADDITIONAL BACKGROUND INFORMATION (Optional) The following optional questions are intended to help determine if USC BEAUFORT is adequately reaching underrepresented groups. Your response (or lack thereof) will not impact your chances for gaining admission. Please check the appropriate response. All information in reference to the following questions will be kept confidential.

15. What is your ethnic background? □ White / Non Hispanic □ Asian / Pacific Islander

□ Black / Non-Hispanic □ Hispanic □ American Indian / Alaskan Native

□ Other

16. Age ____ Gender _____ Please be aware that students with disabilities are assisted through the Office of Disability Services and must register with that office if accommodations are needed. Refer to the USC BEAUFORT Catalog, USC BEAUFORT Student Handbook, and the Baccalaureate Nursing Student Handbook.

Candidates for RN licensure who have been diagnosed or treated for a chemical dependency, psychiatric or mental condition and/or convicted of a crime will be required to consult the Program Nurse Consultant for the South Carolina State Board of Nursing regarding policies for licensure as a registered nurse.

DATE: ___________________ STUDENT SIGNATURE: ______________________________________ The University of South Carolina Beaufort provides equal opportunity and affirmative action in education and employment for all qualified persons regardless of race, color, religion, sex, national origin, age, disability, or veteran status.

RETURN TO: USC Beaufort—Susan C. Williams, PhD, RN, Program Director NURSING Department 1 University Blvd.

Bluffton, SC 29909 (843) 208-8104 scwill@uscb.edu

ATTACHMENT A In the space below, please describe the nature and duration of any health care related experience(s) in which you have participated. The experience may involve a paid or volunteer position and/or family caregiving.

ATTACHMENT B In the space below, please write a statement about your desire to achieve a Bachelor of Science in Nursing. We would like to understand how you decided to become a nurse and the hopes, dreams, and goals you hold for your nursing future.