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. 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 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 _______________________ Date