NURSING STATEMENT OF INTENT
Name ___________________________________ SID #____________________ Other names ___________________
Mailing Address ___________________________ _____________________________ _________________________
Day Phone #: (
) _____________ Evening/Other Phone #: (
1. WHAT IS YOUR GOAL FOR ENTRY INTO THE NURSING PROGRAM?
) __________ e-mail: ______________________
 Fall ______  Winter______ Spring ______
2. APPLICATION REQUIREMENTS
PLEASE
TO BE ELIGIBLE FOR SELECTION INTO THE NURSING PROGRAM ALL STUDENTS MUST COMPLETE THE FOLLOWING :
CHECK
Complete the Community College Application for Admission and Statement of Intent forms. Return them to Clark College
Enrollment Services with the non-refundable fees: $25 for the admission application fee for students new to Clark; $50 for the
program application fee (note: all fees subject to change).
Submit official college transcripts from ALL colleges attended and send updated official transcripts each term.
Students must be in the final quarter of completion for all preliminary requirements and meet the published application
deadline for the quarter of intended program entry in order to apply to the Nursing Program. Application deadlines are as
follows: February 15 (fall start), June 15 (winter start), and September 15 (spring start). Visit the Clark College Nursing website
for additional information: www.clark.edu/clarknursing
A 3.0 or higher applicable grade point average must be achieved in the preliminary requirements. (Includes all courses listed
below, as well as humanities and PE.)
Students must earn a grade of “C” or higher in each preliminary requirement to be eligible for selection.
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3. PRELIMINARY REQUIREMENTS
If you are currently enrolled, or have plans to retake any of these courses you must indicate the institution and
term you plan to take them below. You must enclose a copy of your schedule and submit official transcripts
once grades are posted. There is a 7-year limit on science/social science courses at the time of program entry.
PLEASE
CHECK
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REQUIRED COURSEWORK
COURSE/S TAKEN
INSTITUTION/S
CREDIT
HOURS
ENGL& 101: ENGLISH COMP I
ENGL& 102: ENGLISH COMP II OR
ENGL 109: WRITING ABOUT SCIENCE
PSYC& 200: LIFESPAN PSYCHOLOGY
BIOL& 251, 252, 253: HUMAN ANATOMY
AND PHYSIOLOGY SEQUENCE
BIOL& 260: MICROBIOLOGY
CHEM& 121: INTRO TO CHEMISTRY
NUTR 103: GENERAL NUTRITION
NOTE- Nursing Assistant training is required upon acceptance into the Registered Nursing program.
Students must hold an active verifiable Nursing Assistant Certification prior to starting classes.
Current NAC Credential Number and state issued in (if applicable)
__________________________________________________________________
ARE YOU NOW OR HAVE YOU EVER BEEN ENROLLED IN A COLLEGE NURSING PROGRAM? YES NO
PLEASE LIST ALL THE COLLEGE(S) YOU ATTENDED: ______________________________________________________
________________________________________________________________________________________
I have reviewed the program requirements on the Clark College website. I am aware of entrance requirements, selection processes, required
immunizations, criminal background issues, and all other specific program information. I am aware that completion of pre-entrance requirements
does not guarantee entrance into the program, and understand that additional preparation may be needed for final program selection.
_______________________________________
Signature
Updated: 7/16/2014
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Date