Palomar College Nursing Education
Application for an Associate Degree in Nursing (AA or AS)
This application must be completed in full with all requirements met and documentation completed before submitting the application to the Nursing Office for
consideration for admission. Please review it carefully. Applicants are notified by email that their application has been received.
Name ______________________________________________________________________________
Last
First
Middle
Home Phone _____________________________________________
Previous Name(s) ____________________________________________________________________
Important if your records reflect a name different from above
Alternate Phone (Cell) ______________________________________
Social Security Number _____________________________________________________
Birth Date _______________________
(Required by the Board of Registered Nursing)
Palomar ID ______________________
(Required)
Address _____________________________________________________________ City/State/Zip ___________________________________________________________
Email Address _________________________________________________________ High School/City/State __________________________________________________
(HS transcripts or GED is required to apply. Submit an unofficial high school transcript, diploma or unofficial GED transcript, if no degree was earned)
Important: If you have a change in address, phone number or email, you must contact the Nursing Office in writing. Your admission status will be compromised if we
are unable to reach you. Email changes to: grodriques@palomar.edu. Please initial that you have read this: ___________
Science Prerequisites
GE Required Courses
Course
Number
No. of
Units
Lab
Course
Yes/No?
Year
Completed
Name of College
Letter
Grade
Received
*Anatomy or
Anatomy & Physiology I
*Physiology or
Anatomy & Physiology II
*Microbiology
*Intermediate Algebra
English Composition
Communications/Speech
Psychology
Sociology
Humanities
Applications will be considered only if required coursework (identified by *) has been successfully completed and unofficial transcripts for all of the prerequisites are
included with the application when it is submitted to the Nursing Education Office.
Additional points are given if all of the support courses listed above are completed.
Please Note: All courses used in this application are subject to evaluation and approval by the College for completion of the AA or AS degree. Minimum Science GPA of
2.5 is required to apply. Physiology and Microbiology must be completed within 7 years of the application date, 10 years for Anatomy. Only one (1) repeat of one (1) science
prerequisite course is allowed. Online science coursework is not accepted.
Unofficial transcripts can be submitted with your application. The Palomar College Records Dept. will require official transcripts when you enter the Nursing Program.
It is recommended that you make an appointment with a college counselor to verify all General Education and Major Requirements are fulfilled before entering the program.
College Degrees
___________________________
Name of College
____________________________________________________
Years Attended
______________________________
___________________________
____________________________________________________
______________________________
___________________________
____________________________________________________
______________________________
Allied Health Certificate?
Yes _______ No _______
Vocational Nursing License?
Yes _______ No _______ Please submit copy
Documented recent (within last 3 years) Health Care work or volunteer experience (minimum of 100 hours)? Yes _______ No _______
Life Experience or special circumstances: Documentation required as specified on the Application Checklist
Do you have a documented disability? Yes _______ No _______ (copy of DRC evaluation or letter from Physician describing the disability required)
Documented eligibility for Financial Aid, Cal works, BOGFW-B, Federal Pell grant. Yes _______ No _______ (documentation required)
Are you the first generation of your family to attend college? Yes _______ No _______ (statement from applicant, no other documentation required)
Documented employment during pre-requisite course work? Yes _______ No ______ (documentation from employer on company letterhead verifying dates of
employment)
Are you an EOPS student? Yes _______ No _______ (verification required)
Recent difficult family or personal circumstances? Yes _______ No _______ (statement from applicant, no other documentation required)
Documented Refugee? Yes _______ No _______ (copy of card indicating refugee status)
Documented Veteran? Yes _______ No _______ Spouse of Veteran? Yes _______ No _______ (copy of DD214 form required)
Documented proficiency in language other than English, including American Sign (verify by personal statement of one’s native language, completion of 3rd
semester college coursework, or letter from your employer on company letterhead)
List the Language courses you have taken_______________________________________________________________________ (unofficial transcripts required)
Check the language(s) in which you are fluent: American Sign ____ Spanish ____ Tagalog ____ Arabic ____ Chinese ____ Farsi ____ Russian ____
Various languages of Indian Subcontinent and Southeast Asia ____
Test of Essential Academic Skills (TEAS) version V: Score from FIRST ATTEMPT: ________ (attach a copy of all TEAS (include remediation verification, if
applicable) (official documentation must be transmitted by ATI testing after acceptance)
Complete for statistical purposes only: Gender: Male____ Female____
Asian or Pacific Islander____
Hispanic____
Filipino____
White____
Ethnicity: American Indian or Alaskan Native____
African-American____
Other__________________________________
To the best of my knowledge, the above information is truthful and accurate. Failure to disclose accurate information will result in your application being removed
from consideration by Palomar College Nursing Program.
Applicant Signature __________________________________________________________________
Mail Application to:
OR
Palomar College – Nursing Education, 1140 W. Mission Rd., San Marcos, CA 92069
Bring to the Nursing Office, HS-200 on the San Marcos Campus
Date _________________________________