Application for Selection to Associate Degree Nursing Program

APPLICATIONSELECTION TOPRACTICAL NURSING PROGRAM

HINDS COMMUNITY COLLEGE

1750 CHADWICK DRIVE ● JACKSON, MISSISSIPPI 39204-3490 ● (601) 376-4807

Social Security Number or Student I. D. Number

Home Telephone No. Cell Phone No.

Date of Birth E-mail address

Note:Deadline for file completion for summer part time night/weekend option class –January 31st

Deadline for file completion for fall class – March 31st

Deadline for file completion for spring class – September 30th

INSTRUCTIONS:

A.Complete this form (PLEASE TYPE OR PRINT) and return to 

B. Request the registrar of each high school or college you have attended

to forward an original transcript from that institution to

C.All notifications concerning admissions to the program will be made by mail and/or email

PERSONAL DATA:

Name______

FirstMiddleMaidenLast

Mailing Address______

Street No. / P.O. Box / RouteCityStateZip

Physical Address______

Street No. / RouteCityStateZip

EDUCATIONAL DATA:

List all colleges and professional schools attended.

Name of SchoolCity and State did you graduate? Dates attended

______ Yes No______to______

Mo/year Mo/year

______ Yes No______to______

Mo/yearMo/year

______ Yes No______to______Mo/year Mo/year

CHOOSE ONLY ONE (1) location

 Nursing/Allied Health-DAY  Rankin Campus  Vicksburg Campus NIGHT OPTION-Nursing/Allied

(Starts Fall & Spring) (Starts-SpringSemesterOnly) (Starts-Spring Semester Only) Health Campus

(Starts Summer only)

INDIVIDUAL STUDENT DATA

The following information is needed for counseling regarding licensure/registry requirements.

Do you have a history of alcohol or drug abuse?  Yes No

If yes, have you ever been rehabilitated? ______

Have you ever been convicted of a misdemeanor or felony?  Yes No

If yes, Explain______

Individuals who have been convicted, pleaded guilty or pleaded no contest to certain felony crimes may be unable to attend clinical training or obtain employment in a licensed health care facility in Mississippi. Applicants convicted of a misdemeanor or felony offense may be denied licensure by the Mississippi State Board of Nursing.

I certify that the statements in this application are true and complete to the best of my knowledge, and that I have attended no institution other than those listed therein. I am aware that falsification of information is a basis for denying admission or for immediate termination of enrollment.

Signature______Date______

In compliance with the following: Title VI of the Civil Rights Act of 1964, Title IX, Education Amendments of 1972 of the Higher Education Act, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 and other applicable Federal and State Acts, Hinds Community College offers equal education and employment opportunities and does not discriminate on the basis of race, color, national origin, religion, sex, age, disability or veteran status in its educational programs and activities. The following persons have been designated to handle inquiries regarding the non-discrimination policies:

Dr. Debra Mays-Jackson, Vice President for Administrative Services Dr. Tyrone Jackson, Associate Vice President for Student Services & Title IX Coordinator

34175 HWY. 18, Utica, MS 39175 Box 1100 Raymond Campus (Denton Hall 221), Raymond, MS 39154

601.885.7002601.857.3232