Registered Nursing Online Application

First Name:*

Middle Name:

Last Name:*

Mailing Address:*

City:*

State:*

Zip Code:*

Tech T#:

Date of Birth:*

Phone Number:*

Email:*

I am applying as:*

LPN to RN

Paramedic to RN

If applying as LPN to RN, you must check one of the two options listed below and complete the requested information:

I graduated from an Arkansas State Board of Nursing approved program in Practical Nursing within the past 12 months.

I graduated from an Arkansas State Board of Nursing approved program more than 12 months ago.

If you graduated from an LPN program less than 12 months ago, please enter the program name and your completion date below.

I graduated from an LPN program more than 12 months ago. I understand that because I graduated more than 12 months ago, I must have my employer sign a statement certifying that I have worked a minimum of 1000 hours in the past 12 months in either acute care or long-term care settings in the capacity of an LPN. I also understand I must ensure the statement from my employer is submitted to the Allied Health Administrative Assistant BEFORE the program application deadline.

Yes, I understand

No

If applying as Paramedic to RN, you must check one of the two options listed below and complete the requested information:

I completed from an approved paramedic program within the past 12 months.

I completed an approved paramedic program more than 12 months ago.

If you graduated from a Paramedic program LESS than 12 months ago, please enter the program name and your completion date below. Additionally, you must have your employer sign a statement certifying that you have worked or will have worked a minimum of 600 hours by June 1st. The statement from your employer must be submitted to the Allied Health Administrative Assistant BEFORE the program application deadline, or your application will not be complete, and therefore it will not be considered for admission to the RN program.

I graduated from an Paramedic program MORE than 12 months ago. I understand that because I graduated more than 12 months ago, I must have my employer sign a statement certifying that I have worked a minimum of 1000 hours in the past 12 months in the capacity of an Paramedic I also understand I must ensure the statement from my employer is submitted to the Allied Health Administrative Assistant BEFORE the program application deadline.

Yes, I understand

No

Please indicate if you are currently a student of:*

Arkansas Tech University

Arkansas Tech University-Ozark Campus

Have you previously attended another Registered Nursing program?

No

Yes

If you answered yes to the previous question, where?

Acknowledgment of Essential Functions*

Without reasonable accommodations

With reasonable accommodations

By selecting one of the choices above, I acknowledge that I have read and understand the Essential Functions for the Registered Nursing Student. I believe to the best of my knowledge that I have the ability to learn and perform the Essential Functions:

I, the undersigned applicant to the Registered Nursing Program at Arkansas Tech University-Ozark Campus, understand that participation in a clinical experience is part of the Registered Nursing Program and that participation in a clinical experience includes working as a student at an affiliating agency. I understand that I will be responsible for all travel, meals, and lodging associated with clinical education. I further understand that affiliating agencies have the right to establish requirements for participation in clinical experience. I understand that I am responsible for providing copies of the documentation requested by the affiliated agency. I understand and agree that if I am rejected for participation in a clinical experience by an affiliating agency or if I refuse to submit to checks or tests that are required by an affiliating agency in order to participate in a clinical experience, I may be unable to complete my program of study and graduate from the Registered Nursing Program. I hereby release Arkansas Tech University- Ozark Campus, its employees, and all affiliating agencies from any liability with regard to my participation in a clinical experience and decisions made concerning my participation in a clinical experience. *

Yes, I understand

No

I, the undersigned applicant to the Registered Nursing program at Arkansas Tech University Ozark Campus, understand that additional forms/requirements that can be found on the ATU-Ozark Registered Nursing webpage must be submitted to the Allied Health Administrative Assistant BEFORE the program application deadline in order for my application to be considered complete. I also understand that, if I complete the online application but do not submit these additional forms/required documents, my application will not be considered for admission to the program, as my application would not be fully complete.*

Yes, I understand and will submit the additional documents

No

I certify that the above information and information I will turn into the Allied Health Administrative Assistant is accurate and complete to the best of my knowledge. I understand that falsifying information on any of the requested forms or other documents may be cause for immediate dismissal from the Registered Nursing program.

Yes, I understand

No