practical nursing student application - Continuing Education

EDUCATIONAL DATA
High School:
Name of School City State Parish/County Graduation Date(MMDDYYYY)
*Official transcripts must be mailed directly from the institution to the LSUS Division of Continuing Education office.
GED:
Score
Date Completed
Are you currently attending a college or university (Circle One)? Yes No If yes, institution name:
Have you ever been suspended, dismissed or placed on probation at any college or university for scholastic or disciplinary
reasons (Circle One)? Yes No If yes, give name of institution, date and reason for this action below.
If yes:
Institution Name Dates Attended Reason for leaving
Have you ever applied or been enrolled in another LPN school? Yes
No
If yes:
Institution Name Dates Attended Reason for leaving
List every college or university attended. (Attach separate sheet if needed.) All institutions must be listed regardless of whether credit was
earned or desired or whether work is shown on another transcript.
COLLEGE/UNIVERSITY FROM: Mo/Yr TO: Mo/Yr DEGREE
In the space provided briefly describe your reasons for choosing nursing, and specifically this program:
INVOLVEMENT WITH CRIMINAL JUSTICE SYSTEM
Have you ever been convicted, pled guilty or are you presently charged with a crime (felony) which might be punishable by imprisonment
in a penitentiary (Circle One)? Yes No
Have you ever been committed to a correctional or training institution (Circle One)? Yes No
If the answer to either question is “Yes”, please request a Disciplinary Status sheet which outlines required additional information.
CERTIFICATION
I UNDERSTAND THAT THIS NURSING PROGRAM IS PHYSICALLY, EMOTIONALLY, AND INTELLECTUALLY CHALLENGING. I HAVE NO
MEDICAL OR OTHER CONDITION (HISTORY OR CURRENT) THAT WOULD PROHIBIT MY PERFORMANCE OF THE DUTIES OF A
STUDENT NURSE.
I CERTIFY ALL INFORMATION ON THIS APPLICATION IS CORRECT. I UNDERSTAND THAT FALSE OR INCOMPLETE INFORMATION
MAY MAKE ME INELIGIBLE FOR ADMISSION TO, OR CONTINUATION IN THE LSUS-CE NURSING PROGRAM. I DO HEREBY
AUTHORIZE LOUISIANA POST-SECONDARY EDUCATION TO ACCESS MY ACADEMIC RECORDS.
Signature___________________________________
Date_________________________________

Applications deadline is January 13, 2012; classes begin March 2012.
Application Process
• Complete and pay $10 to process the LSUS PN application.
• Type a one page essay explaining why you are interested in the program AND the profession.
Be sure to include your name on the essay. Essays may be mailed, faxed or delivered to our
office.
• Bring or mail the following documents to our office immediately:
1. Official high school transcripts/GED
2. Official transcripts from all post secondary institutions attended. ALL official transcripts
MUST BE MAILED directly from the institution to:
LSU Shreveport
Division of Continuing Education
ATTN: Sharon Treadwell
One University Place
Shreveport, LA 71115
3. Official ACT score - less than 3 years old; minimum scores are: Math, 17; Reading, 19;
Writing, 17. If you do not meet the ACT requirements click here to learn about other
approved tests.
4. Birth certificate or passport with raised seal (we will copy)
Financial Aid
This program is approved for Financial Aid for those who qualify. Complete your application for federal
aid at www.fafsa.ed.gov (School Code 002013).
Acceptance
All applicants with a complete file will be invited for a personal interview. During the interview you will
be asked to sign a criminal status disclaimer as required by LSBPNE which states you are not
“currently serving under any court imposed order of supervised probation, work-release, school
release or parole in conjunction with any felony conviction(s), plea agreement or any agreement
pursuant to the Louisiana Code of Criminal Procedure, Article 893."
After all interviews are conducted you will be notified of your admission status. Admitted applicants
are required to attend orientation (scheduled before the first class day) and submit the following
documents as required by the LSBPNE:
• Copy of driver’s license or state issued photo ID
• Doctor's report about your physical health (within the past 12 months)
• Proof of immunization (measles, mumps, rubella, tetanus/diphtheria, hepatitis series)
• Finger-print record (two copies, can be obtained from local Sheriff's Office)
• Signed form granting permission for background checks to be sent directly to the Louisiana
State Board of Practical Nurse Examiners
• Money order for $26 payable to the FBI for the background checks to be conducted
Money order for $50 payable to LSBPNE for application review