SUMMERSCOUNTYSCHOOL OF PRACTICAL NURSING
116 Main StreetHinton, WV25951
304-466-6040 / 304-466-6044 fax
Thank you for your interest in the program. This packet should have all the information and forms needed for application. If not, please notify the school.
General information about the program:
The next class is tentatively scheduled to begin October3, 2016. This is a 12-month program. Classes are held Monday through Friday. The program follows county school calendar for holidays, weather delays and cancellations. Internet access, email account, and printing capabilities are required for assignments.
Classes are held at the SummersCountyHigh School. Clinical experiences are scheduled at Summers County and Beckley ARH Hospitals, Summers Nursing and Rehabilitation Center, Main Street Care, Greenbrier Manor, Princeton Community Hospital,Monroe Co Health Clinic and the Robert C. Byrd Clinic. Other clinical sites may also be utilized as available.
Tuition and costs will be determined via the Summers County Board of Education. Applicants who wish to apply forWork Force WV (WIA) funding, and/or Vocational Rehabilitation fundingshould contact those programs to determine eligibility. Students will be required to pay tuition costs to the Summers County Board of Education due to no federal aid being available.
To apply for the program, you must do the following:
1. Complete & return the enclosed application with the pre-entrance test fee by the
due date on the application.
2. Payment of $37.00, made payable to the Summers Co Board of Education, for the pre-entrance test feedue by date on application. Only a cashier’s check or money order will be accepted.
DO NOT SEND CASH. Test fees are nonrefundable. If the school has not received the fee and application by the deadline, a test will not be ordered for you.
The pre-entrance test is the National League for Nursing (NLN) PAX-PN. The test measures general knowledge of verbal ability, mathematic skills and science knowledge. Enclosed is a brochure about a study guide you may wish to purchase. Scores from similar tests taken within the last two years may be accepted. Contact the school for details.
After your application and test fee are received, you will be contacted with more information regarding the test.
REMEMBER: You must return the completed application form and the $37.00
pre-entrance test fee by the due date on the application.
*Applications and test fees must be
mailed to the Summers County School of Practical Nursing
at the address listed above by the deadlines*
** No references required at this time**
If you have any questions, feel free to call the number listed above.
Sincerely,
Brenda Martin RN, BSN
Coordinator
DISCRIMINATION PROHIBITED
As required by federal laws and regulations, the Summers County Board of Education does not discriminate on the basis of sex, race, color, religion, disability, age and national origin in employment and in the administration of any of its education programs and activities. Inquiries may be directed to Kimberly J. Rodes, Title IX and Section 504 Coordinator, Summers County Board of Education, 116 Main Street, Hinton WV 25951. Phone 466-6006; to the State Elimination of Sex Discrimination Project Coordinator, phone 304-558-7864; or to the U.S. Department of Education’s Director of the Office for Civil Rights, phone 1-800-421-3481
APPLICATION
Please Print
Date: ______SS# ______Phone______Cell Phone______
Name: ______
(Last) (First) (Middle) (Maiden)
Mailing Address: ______
Email Address:______
Emergency Contact: ______
Phone: ______
Highest Grade Completed (circle): 8 9 10 11 12 GED College years: 1 2 3 4
High School Name: ______
Address: ______
Have you ever received any type of health occupations training? _____No _____Yes
(Describe): ______
If you have ever worked in a health care facility complete this information:
Facility name: ______
Address : ______
Position : ______
Dates : From ______To ______
Contact Person: ______
Present employer name, address, phone number & contact person(if different from above):
______
______
Name of last employer if different from either above (include name, address, phone & contact)
______
______
List the names and mailing addresses of three (3) people to be character references for you.
DO NOT use relatives or friends. Reference forms will be provided to you after the
pre-entrance test. DO NOT have your references send any information at this time.
______
NameMailing AddressTelephone
______
NameMailing AddressTelephone
______
NameMailing AddressTelephone
Choose a date for the pre-entrance test. Cashier’s Check or Money Order made payable to
Summers County Board of Education
(on the memo line please indicate: for LPN Pre-entrance exam)
MUST be returned with this application.
No Personal checks will be accepted.
TEST DATES:
______March 18, 20169:00 am – 1:00 pm
*37.00 Test Fee DUE: March 8, 2016
______April 29, 20169:00 am – 1:00 pm
*37.00 Test Fee DUE: April 19, 2016
Have you ever taken the pre-entrance test at this school? ___No ___Yes______Year
Have you ever plead not guilty, no contest, or guilty to a felony or misdemeanor? _____No_____Yes
If Yes, _____Felony_____Misdemeanor
Describe the event: When?______
Where?______
Do you experience any condition that may impair your ability to practice?
_____No _____YesDescribe______
Are you taking any prescription drugs? ____No_____YesList______
______
I voluntarily give the Summers County School of Practical Nursing permission to make a thorough investigation of my past employment, references and all other facts stated above. I authorize and release from liability or responsibility all persons, schools, companies and municipalities supplying any information regarding me whether or not it is a matter of record.
Signature of Applicant:______
Date:______
Written 4/96
Revised 4/15, 1/16