Received by______

   	
VOCATIONAL NURSE PROGRAM
APPLICATION

First Name: 			Last Name:		MI: 			
Address: 			Apt#: 		City: 		State: 		ZIP: 		
Contact No.: 		Email Address: 			
Date of Birth:  			Social Security No.: 			
Program Start Date: 		How did you hear about us? 			
Education:  High School Diploma or equivalent?   Yes   No              From a foreign country?   Yes   No 	
If yes, your documents need to be translated, evaluated, and submitted to the Nursing office?  	
Student Aid:    Department of Rehabilitation          CalWorks                                Financial Aid (PELL Grant)        	
                         Veteran’s Administration (VA)          Workforce Connection        Other _________________                             	
Nurse Assistant Certification:  Is your certification active?  Yes    No         Expiration Date: ________________       
Have you completed 350 hours of employment as a Certified Nurse Assistant?   Yes    No  In Progress  
Are you aware of any current or past medical, physical or emotional problems that will keep you from completing the theory and clinical components of the Vocational Nurse Program?        Yes        No	
Have you passed the TABE placement test?   Yes    No             Office use only: Reading ________   Math _________
Have you completed any of the following pre-requisite courses within the past 5 years?  If yes, indicate below:	
Required Pre-Requisite Class                                   Completed?                                             Where?                            
Medical Terminology      (45 hrs)                           ___Yes      ___No        ___ In Progress         ___________________________
Medical Math (Math 103)  (45 hrs)                                     ___Yes      ___No        ___ In Progress         ___________________________
Nutrition                            (33 hrs)                           ___Yes      ___No        ___ In Progress         ___________________________
Anatomy & Physiology   (60 hrs)                           ___Yes      ___No        ___ In Progress         ___________________________	
Vocational Nurse Prep   (36 hrs)                           ___Yes      ___No        ___In Progress          ___________________________
IMPORTANT: If you have completed your Pre-Requisites somewhere other than Clovis Adult, you MUST provide us with OFFICIAL SEALED TRANSCRIPTS with A PASSING GRADE OF 78% OR HIGHER for each class BEFORE submitting your application.	
I understand that I am NOT officially a student for the Vocational Nurse program until I have interviewed, received an VN Acceptance Letter and attended the mandatory orientation.
I understand my signature confirms that all of the above information is true.

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Office Notes:
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Signature									Date