Application for Admissions - Ellis Hospital School of Nursing

Academic
Calendar
2007- 2008

APPLICATION FOR ADMISSION - 2009 SCHOOL YEAR
Applications are currently being accepted for the DAY PROGAM 2009 academic year AND EVENING WEEKEND PROGRAM 2009 academic year. Please complete all sections of the form and once completed, click the "Submit Application" button at the bottom of the form. Upon pressing the Submit button your application will be assigned a Reference Number. Please print off a copy of the reference number page and mail a copy of it with a non-refundable check or money order for $30.00 application fee, payable to Ellis Hospital School of Nursing, to the below address: Ellis Hospital School of Nursing 1101 Nott Street Schenectady, NY 12308 Applications will not be processed until all components of the application process are received by the School. It is the applicant' s responsibility to contact the School of Nursing at 518-243-4471 to verify the status of an application - including the receipt of all fees and transcripts - within 2 weeks of submitting the online application. Failure to do so will result in the application NOT being processed. Partially completed applications will not be processed. IF YOU ENCOUNTER A PROBLEM WHEN PRESSING THE SUBMIT BUTTON .....GO BACK TO THE HOME PAGE AND START OVER, DO NOT PUSH BACK. * Denotes a required field
Please complete ALL sections of the Application. Partial applications WILL NOT be processed. A $30.00 application fee must be received at the School within 2 weeks of an application submission date or the application will be discarded.

Section I: All fields in this section are REQUIRED. If you do not fill in all of the informationin this section the application will be rejected.
First Name*			Last Name*
Home Address*			City*
State*			Zip Code*
County*			Telephone*
Date of Birth (MM/DD/YR)*
Section II: Optional Information
U.S. Citizen	Yes No		Social Security Number
e-mail address
Please list maiden name and all other names your records have been issued under:
Section III: Emergency Notification - All fields in this section are REQUIRED.
Name*			Relationship*
Address*			Day Telephone*
City*			Evening Telephone*
State*
Zip*
Section III: COMPLETED COURSE WORK: Admission to either program at the Ellis Hospital School of Nursing (Traditional Day OR Evening/Weekend) requires the completion of certain prerequisite course work. For the Program you are applying for please check the following prerequisite courses you have completed.
Traditional Day Program		Evening Weekend Program
	Chemistry		Anatomy & Physiology I
	Biology		Anatomy & Physiology II
	Algebra		Microbiology
	One Other Math

Please identify your plan to complete the pre-requisites not completed at this time. (Note: Official transcript(s) of pre-requisite course(s) is required. Lack of completion of the pre-requisites may delay the application process.)


Section IV: SECONDARY EDUCATION (High School): List all high schools attended. Please have official transcripts mailed to the Ellis Hospital School of Nursing, 1101 Nott Street, Schenectady, NY 12308.
Date From*	Date To*	Name of School*	City and State*	Diploma Received
				Yes No
				Yes No
				Yes No
Section V: POST SECONDARY EDUCATION: List all formal education beyond high school. Please have official transcripts mailed to the Ellis Hospital School of Nursing, 1101 Nott Street, Schenectady, NY 12308.
Date From	Date To	Name of School	City and State	Credential Earned (Diploma, Certificate, Degree, or No. of Credits)



Section VI: EMPLOYMENT: List all work experiences, both full and part time, since high school beginning with most recent.
Date From	Date To	Title of Position	Employer	City and State



Section VII: GENERAL INFORMATION:
Have you previously applied for admission to the Ellis Hospital School of Nursing?			Yes No
If you applied previously please specify date of application. (MM/DD/YR)
What program are you applying to enter?			Day Evening / Weekend
When do you desire to enter this school?
Personal Essay : Academic credentials provide a perspective of you as a student. Please respond to ONE of the following statements to provide the selection committee with further personal insight. (Explanations should not exceed this space.*)
	1. Discuss activities, interests, and/or volunteer experiences you have had in school or in community organizations. 2. Describe an experience in which you have had to persevere to succeed. 3. Explain why you feel you have more potential than your academic record indicates.



Section VIII: REFERENCES: List complete name and full address of 3 references from academic, employment and / or professional sources only. By providing this information you are granting permission for the School of Nursing to contact these references. Incomplete information will delay the application review process.
1. Name*		Position / Title*
Address*		Phone Number*
City*		Zip*
State*
2. Name*		Position / Title*
Address*		Phone Number*
City*		Zip*
State*

3. Name*		Position / Title*
Address*		Phone Number*
City*		Zip*
State*

The Family Educational Rights and Privacy Act permits us to request, but not to require, that you waive your right to inspect submitted references. The right, which we request that you waive, would arise if you were an enrolled student at this school and if the reference were maintained after your enrollment. In considering whether you will waive, please be advised that the information contained on this reference will be used to evaluate you as an applicant for admission to this School of Nursing.

Please check the appropriate response:
I elect to waive rights of access to and review of this information:
I elect NOT to waive rights of access to and review of this information:
Section IX: NON-DISCRIMINATORY POLICY: This information is used for statistical purposes with the goal of commitment to equal opportunity and racial justice. It is not required, however, we would appreciate you providing this information.
	Male		Hispanic (Spanish Origin)
	Female		Asian or Pacific Island, Non-Hispanic
	White, Non-Hispanic		Non-Resident from:
	Black, Non-Hispanic		Other:
	American Indian, Non-Hispanic
A history of a felony or misdemeanor conviction may jeopardize the applicant's eligibility for professional licenYes. Any questions reguarding these issues should be presented to the Committee on Professions, State Education Department for clarification.

By Pressing the "Submit Application" button, I attest that, to the best of my knowledge, the information on this application is complete and accurate.
	Press 'Submit Application' only once

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