* = Required Information

Student Information

American Indian or Alaskan Native
Asian or Pacific Islander
Black Non-Hispanic
White Non-Hispanic
Other, please specify

Academic Information

Yes No
Yes No

Employment Information

Yes No

Emergency Contact

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and or hospital procedures as may be performed or prescribed by the attending physician and or paramedics and waive my right to informed consent of treatment
I release Americare Technical School from liability in case of accidents during my classroom/lab/clinical rotations.

Financial Information

Own Funds
WIA Funding
Credit Union
Ben Franklin
Others, please specify:
Enroll in the School Payment Plan
Pay per course
Referred By
Yes No
Yes No

The Board of Nursing may refuse to admit an applicant for the licensure examination, or may revoke, suspend, or otherwise discipline a license based upon satisfactory proof that the person “... (1) is convicted of a felony;(2) is guilty of professional misconduct as defined by the Board...” The Board’s Legislative Rules, states that the Board can take disciplinary action against an applicant or licensee who was convicted of a felony or misdemeanor with substantial relationship to the practice of practical nursing in a court of competent jurisdiction...”

I acknowledge the above statement and declare that to the best of my knowledge the above information and statements provided on this application are accurate and truthful. Falsification of this application is grounds for dismissal from the program.

Core Performance Standards for Admission and Progression

Nursing involves the provision of direct care for individuals and is characterized by the application of knowledge in the skillful performance of nursing functions. Therefore, in order to be considered for admissions or be retained in the program after admission, all students must be able to demonstrate the following abilities:

Issue: Critical Thinking/ Coping

Standard : Critical thinking ability sufficient for clinical judgment. Ability to make fast decisions in stressful situations in a professional manner.

Examples of Necessary Activities (not all inclusive) Identify cause-effect relationships in clinical situations, develop nursing care plans and display good coping mechanisms.

Issue: Interpersonal

Standard : Interpersonal abilities sufficient to interact with individuals, families and groups from a variety of social, emotional, cultural and intellectual backgrounds.

Examples of Necessary Activities (not all inclusive) Establish rapport with patients/clients and colleagues.

Issue: Communication

Standard : Communication abilities sufficient for interaction with others in verbal and written form.

Examples of Necessary Activities (not all inclusive) Explain treatment procedures, initiate health teaching, document and interpret nursing actions and patient/client responses.

Issue: Mobility

Standard : Physical abilities sufficient to move from room to room and maneuver in small spaces.

Examples of Necessary Activities (not all inclusive) Move around in patient rooms, work spaces, and treatment areas; administer cardiopulmonary procedures.

Issue: Motor Skills

Standard : Gross and fine motor abilities sufficient to provide safe and effective nursing care.

Examples of Necessary Activities (not all inclusive) Calibrate and use equipment; position patients/clients.

Issue: Hearing

Standard : Auditory ability sufficient to monitor and assess health needs.

Examples of Necessary Activities (not all inclusive) Hear blood pressure accurately, hear alarms, emergency signals, auscultatory sounds, and cries for help.

Issue: Visual

Standard : Visual ability sufficient for observation and assessment necessary in nursing care.

Examples of Necessary Activities (not all inclusive) Observe patient/client responses. Prepare and administer medication accurately.

Issue: Tactile

Standard : Tactile ability sufficient for physical assessment.

Examples of Necessary Activities (not all inclusive) Perform palpation, functions of physical examination and/or those related to therapeutic intervention, e.g. sense temperature change, assess peripheral pulses, and insert a catheter.

Issue: Strength/Stamina

Standard : Sufficient stamina to provide patient care and related responsibilities for extended periods of time (8-12 hours).

Examples of Necessary Activities (not all inclusive) Adapt to shift work. Lift, without restrictions, from standing position.