MCC-Penn Valley
Division of Nursing Program Application
Please print the application and legibly print in black/blue ink, completing all portions. Incomplete applications will not
be considered. Select the program you want to be considered for:
PROGRAM
Practical Nursing 
LPN-ADN Bridge  Professional Nursing: Day Evening/Weekend 
Personal Information
Name full: ____________ ___________________________________________________________________________
(Last)
(First)
(Middle)
Other names used or that may appear on transcripts:____________ __________________________________________
Student ID: __________________________________________ Social Security Number:______-_____-____________
Address: _________________________________________________________________________________________
City:___________________________________ State:____________________________ Zip Code:______________
Email address: ____________________________________________________________________________________
Home Phone (
) _______________Cell Phone (
) ________________ Work Phone (
) ___________________
Educational Information
List all Colleges/Universities/Technical Schools other than MCC-KC attended (list most recent first; if more room is
needed please use the back of this page). Official transcripts from all post high school institutions other than MCC-KC
must be received and evaluated in the Student Data Center prior to the start of any given application period to be
considered:
Metropolitan Community College
Student Data Center
3200 Broadway
Kansas City, MO 64111
Failure to disclose all transcript information may result in your application not being considered.
Name of Institution (Please spell out)
State
Dates of
Major/Area of
Attendance
Study
1/7/2014 se/ec
Graduation Date
(if applicable)
EMERGENCY CONTACT INFORMATION
Name and phone number of emergency contact:
Name
Relationship
10-digit phone number
TEASTM Test
•
•
Attach to this application form a copy of the test scores for all TEAS tests you have taken.
Those can be accessed from your ATI home page. The Individual Performance Profile that shows your Adjusted
Individual Total Score is needed.
If you took your TEAS test at a location other than MCC-Penn Valley, you must contact ATI to have your scores
sent to “MCC-Penn Valley Nursing Division.” For your application to be considered, the TEAS test scores from
all external locations must be transferred to and received by MCC-Penn Valley prior to the start of the application
period in which you are applying.
Signature
I certify that all information on this application is complete and correct:
(Signature)
(Date)
Application must be postmarked or received in nursing division office by published application deadlines for each
semester (please see admission criteria).
*Faxed or emailed applications are not accepted.
Application Submission
Mailing Address:
MCC-Penn Valley
Nursing Division
3201 Southwest Trafficway
Kansas City, MO 64111
1/7/2014 se/ec
To submit application in person:
MCC-Penn Valley Nursing Division
Health Science Institute
3444 Broadway – Suite 408
Kansas City, MO 64111