Application for Admission

JAMESON MEMORIAL HOSPITAL
SCHOOL OF NURSING
1211 WILMINGTON AVENUE
NEW CASTLE, PA  16105-2595

Admission to the School is open to all qualified applicants regardless of sex, marital status, age, race, color, national origin, religion, disability, or sexual orientation.  Applicants must be citizens of the United States or have Permanent Resident Status with the United States Immigration and Naturalization Services.

Give careful consideration to each question on this application.  Complete the application and return as soon as possible to the Director of Professional and Allied Health Education at the above address.  The application should be accompanied by a fee of $50.00, made payable to Jameson Memorial Hospital, which is NON-REFUNDABLE.  

PERSONAL:
Date of application______________________________
Date of Desired Admission________________________

Please type or print all information:

___________________________________________________________________________________
Last Name                    Maiden Name                    First Name                       Middle Name

___________________________________________________________________________________
Address

____________________________________________________________________________________
City                                                 State                              Zip                        County

Phone Number:__________________    Social Security Number_________________________ 

Cell Phone Number________________________            Email Address____________________________

                                                                                           May we contact you via email?  Yes___ No___

If a minor - Name and address of parents or legal guardian

_______________________________________      _________________________________
Name                                                                              Relationship

_____________________________________________________________________________________
Address

______________________________________________________________________________________
City                                                 State                                 Zip                      Phone Number

U.S. Citizen _______yes  ________ no        Have Permanent Resident Status with the US INS? _____yes _____no

Have you served in the U.S. Armed Forces?_______Branch:_____________Dates:___________

According to the Pennsylvania State Board of Nursing, an R.N. license will not be issued to persons who have been convicted of a felony prohibited by "The Controlled Substance, Drug, Device and Cosmetic Act" or a felony relating to a controlled substance.

Have you ever been convicted of any felony or misdemeanor, and/or do you currently have any criminal charges pending and unresolved in any court?   Yes______    No ______
Have you ever been convicted of any crime associated with alcohol or drugs in any court? Yes_____  No________
Have you ever been convicted of any crime associated with sexual misconduct in any court?
Yes______ No________
If you answered yes to any of the above three (3) questions, attach explanation and documentation.
*Conviction includes judgment found guilty by a judge or jury, pleaded guilty or nolo contendere, received probation without verdict, disposition in lieu of trial, or ARD.  (The Pennsylvania State Board of Nursing will not issue a license to an applicant who has been convicted of a felony unless ten (10) years have elapsed from the date of conviction).  It is the applicant's responsibility to contact the Pennsylvania State Board of Nursing to clarify their individual situation.  The Board may be contacted at 717-783-7142.

EDUCATION:
Information on high schools attended, including ninth grade:

Have you had Algebra? Yes______  No______                                 These courses must be completed with a grade of
Have you had Chemistry with a Lab?   Yes_____  No______             "C" or better.
Have you had General Biology with a Lab?  Yes______ No______
Information on other schools attended beyond high school:

Have you ever taken a Nursing Pre-Admission Exam? ___________  When?_____________________

Name of Exam__________________________________________________ 

Other health related education/experience:  
   ______State-tested Nursing Assistant (STNA)
   ______ EMT/Paramedic
   ______ Licensed Practical Nurse (LPN)
   ______ Medical Assistant
   ______ Other_____________________________

EMPLOYMENT:    List work experiences from present to past.

May we ask your present and/or past employers about you?  Yes_______ No _________
Have you ever applied to this School before?  Yes______ No______ If yes, when?____________

Have you ever been enrolled in an RN nursing program?  Yes_______ No______ 

If yes, where/when__________________________________________________

Do you consider yourself to be able to perform all of the activities required by the planned program of studies without endangering other students, patients or employees?  Yes ______  No_______

What factors contributed to your decision to apply to Jameson?  (Check all that apply)
   ____Family/Friends         _____Alumni                     _____Open House     _____Career Fair
   ____Advertisement          _____Guidance Counselor _____Tour of School  _____Other______ 

How did you learn about the nursing program at Jameson?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

REFERENCE FORMS (Click here)
Three references are required from current teachers, school counselors, employers, etc.  No family member or close friends.  Submitting inappropriate references will delay the admission process.  Submit the three (3) reference forms with your application or have your references mail the forms to the school address which is listed on the form.  Your application is not considered complete until the application, the $50.00 application fee, and the three (3) reference forms have been received.
                 

ESSAY:
In the space provided or on a separate piece of paper, please provide a brief account of any experiences or accomplishments that have contributed to your personal growth and influenced your decision to become a nurse and your plans for the future.








Person to be notified in case of emergency:
______________________________________________________________________________________
Name                                                                             Relationship
_______________________________________________________________________________________
Address
_______________________________________________________________________________________
Phone No.                                                                    Cell Phone
_______________________________________________________________________________________


I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief and hereby grant Jameson Memorial Hospital School of Nursing permission to verify such answers.  I understand that any false statement on this application may be considered sufficient cause for rejection of this application, or for dismissal if such false statement is discovered subsequent to my admission.  If this application is considered favorable, I agree to abide by and comply with all of the rules of the Jameson Memorial Hospital and the Jameson Memorial Hospital School of Nursing.

________________________________________      ___________________________
Signature                                                                            Date