Application: Registered Nurse Track

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Lutheran School of Nursing Application
Mr. Mrs. Ms. Date SSN

Last Name Address City Home Phone Number Is English your native language? Yes Spring

First Name

MI

Maiden and/or previous last names

State

Zip Code Country of Citizenship

Email

2nd Phone Number No Fall Year:

VISA Type ( international student)

Term you wish to begin classes at LSN:

Registered NurseTrack

LPN to RN Track

Spring Yes

Fall Year: No

Do you plan to take prerequisite university courses at LSN prior to entering one of the nursing tracks? Please see the LSN Bulletin or website for required university courses. If yes, date you wish to start university courses at LSN Spring Fall Year:

List your graduating high school. All technical schools, colleges and universities you are attending or have attended must be listed. Any omission of school(s) may result in cancelation of application or dismissal from the program. Contact EACH school to request an official transcript be sent directly to Admissions at Lutheran School of Nursing.

Diploma? No

High School or GED School School School School School

City and State City and State City and State City and State City and State City and State

Dates Attended Dates Attended Dates Attended Dates Attended Dates Attended Dates Attended No Yes No Yes Yes No

Yes

Degree Degree Degree

Degree Degree

Have you ever made application to Lutheran School of Nursing in the past?

Date

Have you ever attended any other school(s) of nursing including practical nursing program(s)?

Have you taken an ACT and received a composite score of at least 20 or a comparable SAT composite score ? If "YES" to either ACT or SAT scores, have score sent directly to Admissions at Lutheran School of Nursing. Note: If you took the ACT or SAT in High School, ask if the score is on your transcript when you request it.

No

Have you ever pled nolo contendere or been convicted of a crime other than a traffic violation? If YES, explain:

Yes

How did you hear about our school? Friend or Relative

Website

Yellow Pages

Newspaper /Magazine

High School or College

Current Student or LSN Alumni Name:

Agreement
I hereby certify that the information in this application is correct to the best of my knowledge. I understand that misrepresentation or omission of information called for on this application is cause for cancellation of my application or dismissal from the school if I have been enrolled. I have read and/or discussed the Essential Functions Necessary in the Role of the Student Nurse which can be found in the School Bulletin and website and believe I would be able to perform them. If I enroll, I will provide the School with documentation of current immunizations as required, a physical examination and such future examinations as may be required by Lutheran School of Nursing. I understand that: • an acceptable criminal background check and a negative drug screen is required for class attendance. • continued enrollment, if selected, is contingent upon my being physically, mentally and medically able, with or without reasonable accommodation, to successfully perform the essential functions necessary in the role of the student nurse. • my fingerprints must be taken when I apply for a Registered Nurse license. If I enroll, I agree to conform to all rules, policies and regulations of Lutheran School of Nursing. I have received a copy of section 335.066 of the Missouri Nurse Practice Act which is available in the School Bulletin and website and understand that the privilege of taking the licensing examination is dependent upon my satisfactory compliance with this law. Completion of the program does not guarantee eligibility to take the licensure exam. Applicant Signature Date

Applications are not reviewed by the Admissions Committee until they are complete. See the School Bulletin or Website for requirements for each Track. I have: Completed and signed the...
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