CRUSOE-HOLIFIELD
PRACTICAL NURSING
PROGRAM
Lively Technical Center
Health Education Department
500 North Appleyard Dr.
Tallahassee, FL 32304
Phone (850)487-7449
Fax (850)487-7478
Website: www.livelytech.com
APPLICATION DEADLINE FOR January 2016 DAY ADMISSION:
October 8, 2015 by 4:00pm
Crusoe-Holifield Practical Nursing Program Application Packet
PROGRAM DESCRIPTION:
The Crusoe-Holifield Practical Nursing Program is designed to prepare students for successful passage of
the NCLEX-PN and future employment as a Licensed Practical Nurse. Clinical experiences are included as
an integral part of this program. The program is approved by the Florida State Board of Nursing.
PROGRAM BEGINS:
January 2016 (Day Program)
PROGRAM LENGTH:
Day program: Three semesters
PROGRAM HOURS:
Day program (30 hrs/wk):
Classroom: M-Th, 8am-4pm
Clinical: 7.5 hours between 6:45am and 11:15pm 1 – 4 days a week
Externship: 30 hrs/wk – variable
PROGRAM LOCATION: Lively Technical Center
Health Education Department, Building 15
500 North Appleyard Drive
Tallahassee, FL 32304
Clinical Locations – Various
Externship Locations – Various
GENERAL REQUIREMENTS (Please READ)
Applicants seeking admission to the Practical Nursing Program must:
 Be at least 18 years of age.
 Complete and return the application to the Lively Health Education Department.
 Have a high school diploma or equivalent.
 Provide three references.
 Attend a General Information Program Session. (after the application deadline)
 Provide proof of current immunizations, including the Hepatitis B series, MMRx2, Varicella and Tetanus.
We can no longer accept a history of chicken pox as proof of immunity. If you do not have current
immunizations for MMR or Varicella, then you need a titer as proof of immunity. An annual PPD
(tuberculin skin test) is also required. Students with a history of positive PPD will need a current negative
chest x-ray.
 Take CPR for Healthcare Providers (BLS) on campus during the first course of the program, no
exceptions. Certification must be maintained throughout the duration of the Program.
 Be able to pass random drug screenings during the length of the program. Students with positive drug
screen results will not continue in the program.
 Pass a Level 2 criminal background screening prior to enrollment, at the student’s expense. In order to
participate in the mandatory clinical practicum, as well as to obtain licensure, students must have a clear
background.
Applicants must successfully complete all of the required criteria and have all relevant documentation on file with
the Lively Technical Center (LTC) Health Education Department, by the specific date on the application. Meeting
the criteria for selection does not guarantee admission to the Crusoe-Holifield Practical Nursing program. Final
selection will be based on the qualified applicant pool and space available.
Note: #1 through #5 below must be completed and submitted by the application deadline.
Late and/or incomplete packets will not be considered.
1. PERSONAL INFORMATION FORM
Please complete the Personal Information Form that is included in this packet.
2. TESTING For more information, please contact The Testing Center at: 850-487-7467
A. Prospective students must take the Test of Adult Basic Education (TABE), Level A. TABE exit
requirements for the Practical Nursing Program are 11.0 in Reading, Language and Total Math.
TABE scores are valid for two (2) years. Prospective students will go to the Registration window
in Building 8 to pay for the exam then report to the Testing Center. Prospective students with an
Associate Degree or higher, have successfully completed the College Level Academic Skills Test
(CLAST), or have already met the minimum scores, within the past two years, on the CPT, ACT,
MAPS, SAT or ASSET are exempt from the TABE exam with the appropriate official
documentation. NEW as of 3/1/2014, you may also be exempt from TABE if you earned a valid
Florida Standard high school diploma since 2008 or if you are an active duty member of any branch
of the US Armed Services. You must have proof of the appropriate documentation to be exempt.
B. ATI-TEAS
(ASSESSMENT TECHNOLOGY INSTITUTE - TEST OF ESSENTIAL
ACADEMIC SKILLS) ALL applicants must take the ATI-TEAS Nursing Entrance Exam. ATITEAS scores are valid for two (2) years; however, only the most recent score will be considered
for admission. Applicants are encouraged to test early. There is a *$80.00 fee for this exam.
Applicants will go to the Registration window in Building 8 to pay for the exam then report to the
Testing Center. Once accepted, students will also be required to take ATI Standardized NCLEXPN Testing Preparation Exams throughout the Program. The current desired proficiency level for
the PN program is 55.0.
3. HEALTH REQUIREMENTS
Applicants are required to be in good mental and physical health and must submit proof of a recent medical
evaluation (not more than 6 months old; see attached form). If, after acceptance, a student’s health status
changes, further documentation may be required stating the student is physically able to continue the
Program. Applicants are also required to provide proof of the following current immunizations:
 Tetanus, within the past 10 years (Td or Tdap)
 MMR x2 (given on or after the applicant’s first birthday). Official documentation of immunity is
also acceptable.
 Hepatitis B series. Official documentation of immunity is also acceptable.
 Varivax x2 or proof of immunity. We NO LONGER accept that you have had a history of having
Chicken Pox
 PPD/Tuberculin skin test within past 12 months.*
*PPD/Tuberculin skin testing is valid for one (1) year from date of administration. Students will
be required to maintain current PPD/Tuberculin skin testing throughout the duration of the
program. Students who test positive for tuberculosis must show proof of a negative chest x-ray
taken within the past year to satisfy this requirement.
4. REFERENCES Applicants must submit three current reference letters: two professional references
(recent employers, former teachers, counselors, etc.) and one personal reference (may not be family
member).
5. OFFICIAL TRANSCRIPTS Students are required to submit proof of an academic high school diploma,
general equivalency diploma (GED), or a validated foreign transcript equivalent to the LTC Health
Education Department. You will need to provide the official transcript during the registration process if
you accepted in the program.
6. GENERAL INFORMATION MEETING After submitting a completed application to the LTC Health
Education Department, applicants will be notified about attending a mandatory General Information
meeting. At least two meetings will be scheduled prior to student selection; the date and time of these
meetings will be given to all applicants when the application is submitted. This meeting provides potential
students with an overview of the Crusoe-Holifield Practical Nursing Program, registration process,
financial aid, and general LTC campus information. This is also an opportunity for applicants to ask
questions about the program. Further information may be obtained by calling the LTC Health Education
Dept. at 850-487-7449.
AFTER YOU HAVE BEEN ACCEPTED:
7. CRIMINAL BACKGROUND CHECK If accepted into the program, students must undergo a Level 2
criminal background check prior to registration for the program. All students must pass the background
check. Instructions for obtaining the background screening will be included the Practical Nursing Program
acceptance letter.
8. DRUG SCREENING Drug screening is not required prior to admission into the program. However, all
students must submit to and pass two random drug screenings after entering the Practical Nursing Program
and prior to having access to the clinical health care facilities utilized in the Program. This is a Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) requirement demanded of all acute
care facilities in Florida. Students who do not pass a random drug screening will not be able to access
the clinical facilities and therefore will not be able to continue in the program.
DISABILITY SUPPORT SERVICES:
If you have question regarding a disability accommodations, please contact LTC Student Services in Building 9.
FINANCIAL AID:
Financial Aid is available for this program based on eligibility. Qualifying students will receive the Federal Pell
Grant. Loans and other financial arrangements are a personal decision and not handled at Lively Technical
Center. The Financial Aid Office is located in Student Services, Building 9, phone number 850-487-7473.
Please direct all financial aid questions directly to their office.
ACCEPTANCE INTO PROGRAM:
Applicants who have met the requirements for placement will be placed into a selection pool and chosen based
on the number of available slots. Should the number of eligible applicants exceed the number of openings offered;
students will be admitted based on a defined point system. In the event of a tie, a lottery selection system will be
used.
ACCEPTANCE/REGISTRATION:
Applicants who are selected will be notified approximately two weeks after the final information session is
complete. If an applicant is selected and does not complete the registration process, the applicant must reapply
and be considered based on the applicant pool at the time of reapplication.
All expenses are incurred AFTER acceptance into the Crusoe-Holifield Practical Nursing Program
EXCEPT for the physical exam, immunizations, ATI-TEAS and the TABE.
PERSONAL INFORMATION
Date ______________________
PLEASE PRINT—BLUE OR BLACK INK ONLY
Date of Birth _______________________________
Place of Birth _________________________________________
Name __________________________________________ SS# _________________________________________________
Address _______________________________________ City/State __________________________ Zip _______________
Home # (
) _____________________ Work # (
) _____________________ Cell # (
) ____________________
Email Address ________________________________________________________________________________________
Emergency Contact ___________________________________________
Phone# (
) _________________________
EDUCATION
High School _______________________________________City/State __________________________________________
Highest grade completed ____________ Year _____________
Previous Nursing School ________________________________
College ________________________ Degree awarded _________
Circle one: Diploma
GED
City/State ___________________________________
City/State ___________________________________
Military _____________________________________________________________________________________________
Education as Certified Nursing Assistant, Patient Care Assistant, Patient Care Technician or Medical Assistant
Name of School ______________________________________________________________________________________
Certification Awarded
Yes
No
Date the Certificate was awarded __________________________________
Proof Required at time of Application
EMPLOYMENT RECORD
Present ____________________________________
Title/Position __________________________________________
Dates of Employment: From __________ to _________
Previous ___________________________________
Title/Position __________________________________________
Dates of Employment: From __________ to _________
Previous ___________________________________
Title/Position __________________________________________
Dates of Employment: From __________ to _________
The information on this application is true and factual.
Signature: _______________________________________________________ Date: ________________________
Crusoe-Holifield Practical Nursing Program
Student Health Assessment Record
THIS FORM MUST BE COMPLETED BY YOUR HEALTH CARE PROVIDER. Any falsification of this record will result in
immediate dismissal from the program (if accepted).
NAME (please print):______________________________________________________________________________
Last
First
MI
DATE OF BIRTH: _____/_____/_____
Male ___
Female ___
1. MMR (Need proof of two MMR vaccines or one mumps, two measles, and one rubella.
Any person born before 1/1/57 will need proof of rubella immunization or positive titer.)
Date of MMR #1: _______________
Date of MMR #2: _______________
OR
Antibody titers:
Mumps titer date: _______________ Results: Immunity/Not immune
Rubeola titer date: ______________
Results: Immunity/Not immune
Rubella titer date: _______________ Results: Immunity/Not immune
If not immune, will require MMR x2.
2. Tetanus (Td or Tdap with the last ten years):
Date: _______________
3. Hepatitis B series:
_______________
_______________
_______________
Hepatitis B #1 date
Hepatitis B #2 date
Hepatitis B #3 date
OR
Antibody titer date: ______________ Results: Immunity/Not immune
4. Varicella: History of having Chicken Pox is no longer accepted
Date of 1st dose: _______________
Date of 2nd dose: _______________
OR
Varicella titer date: __________ Results: ________ (Lab value)
5. PPD (TB Skin Test):
Date taken: _______________
Results: Positive
Negative
Chest x-ray, if positive PPD: Date: _______________ Results: __________
The signature below indicates that I have examined this candidate and find HIM/HER physically able to
perform the duties of a Practical Nurse without limitations.
Verified by:
___________________________________
Name of Physician’s Office/Health Center
____________________________________
____________________________________
Address of Office
____________________________________
Physician’s Signature
_____________
Date