UAA School of Nursing 3211 Providence Drive, HSB 101 Anchorage, AK 99508

(907) 786-4550 Phone (907) 786-4559 Fax [email protected]

APPLICATION FOR ADMISSION - UNDERGRADUATE NURSING PROGRAMS ASSOCIATE DEGREE (AAS)-Anchorage [Application deadline—February 1st] ASSOCIATE DEGREE (Pick One: Juneau, Kenai, Mat-Su) [Application deadline—May 1st] ASSOCIATE DEGREE (Pick One: Ketch., Bethel, Dilling., Homer, Kotz., Nome, Sitka, Valdez) [Application deadline—July 1st] ASSOCIATE DEGREE (LPN  RN) (Anchorage) [Application deadline—May 1st and October 1st] BACCALAUREATE DEGREE (BS) - Pre-Licensure - Fairbanks [Application deadline - March 1st] BACCALAUREATE DEGREE (BS) - Pre-Licensure - Kodiak [Application deadline - May 1, 2018; March 1, 2019 and beyond] BACCALAUREATE DEGREE (BS) - Pre-Licensure - Anchorage [Application deadline- October 1st]

Applicant: Please mark appropriate program. If applying to both AAS and BS (Pre-Licensure), mark both programs. Materials must be received by published deadline. Name _____________________________________________________________________________________________________ (Last, First MI)

Previous Name(s) ____________________________________________________________________________________________ Student ID # _______________________________ Email Address ____________________________________________________ Home Phone _________________________ Work Phone __________________________ Cell Phone _______________________ Mailing Address _____________________________________________________________________________________________ ___________________________________________________________________________________________________________

Secondary Education: ________________________________________________________________ Diploma _______ GED _______ Year ________ Name of School

City/State

Post-Secondary Education (College, University, VoTech, Military, etc.): ___________________________________________________________________________________________________________ Name of School

City/State

Degree year and/or credits

___________________________________________________________________________________________________________ Name of School

City/State

Degree year and/or credits

___________________________________________________________________________________________________________ Name of School

City/State

Degree year and/or credits

Recommendations: Please list the three individuals who will be submitting letters of recommendation. Letters from relatives will not be accepted. Two individuals should be people you have dealt with on a professional basis, i.e., instructor, employer. One can be a non-relative who knows you well. Forms are enclosed, and may be mailed separately to the School of Nursing. ___________________________________________________________________________________________________________ Name

Position

Telephone Number

___________________________________________________________________________________________________________ Name

Position

Telephone Number

___________________________________________________________________________________________________________ Name

Position

Telephone Number

LPNs: Nursing School (LPNs fill in this section) _________________________________________________________________________________________________________ Name of School

City/State

Diploma/Degree Year

Provide copy of nursing license with this application. Work History: Begin with the most recent position (include volunteer work). (A resume may be attached) Date of Employment

Employer

Job Title/Responsibilities

_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

AAS: For AAS applicants, the following must be on file to be eligible for the ranking process: 1. 2. 3. 4. 5. 6. 7.

BS:

Acceptance to UAA as a Pre-major in AAS Nursing. Official transcripts and evaluations from non University of Alaska institutions. Verification of the required prerequisite courses. (see AAS Plan of Study) ACT, SAT or ACCUPLACER scores or 15 college credits. This School of Nursing application and confidential form. Three letter of recommendation forms. (enclosed) HESI Pre-Admission Examination taken prior to the application deadline.

For BS applicants, the following must be on file to be eligible for the ranking process: 1. 2. 3. 4. 5.

Certificate of Admission from UAA for Pre-major in BS Nursing. Official transcripts and evaluations from non University of Alaska institutions. Verification of the required prerequisite courses. (see BS Plan of Study) This School of Nursing application and confidential form. KAPLAN pre-Admission examination taken prior to the application deadline.

The entire School of Nursing Application to the major must be received by the School of Nursing no later than the published application deadline. Letters of recommendation for the AAS appliction will not be accepted after the deadline date. Students are responsible for ensuring that everything is received by the deadline. Applications can be submitted to the School of Nursing by any of the following methods: email, fax, mail, or in person

___________________________________________________________________________________________________________

Signature

UA is an AA/EO employer and educational institution and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination.

Date

Revised 1/30/2018 Please see other side of document

(907) 786-4550 Phone (907) 786-4559 Fax [email protected]

UAA School of Nursing 3211 Providence Drive, HSB 101 Anchorage, AK 99508 LETTER OF RECOMMENDATION UNDERGRADUATE NURSING PROGRAM

BBBBB$662&,$7('(*5(($$6 $QFKRUDJH [Application deadline—February 1st] BBBBB$662&,$7('(*5((Circle One-XQHDX.HQDL, Mat-Su [Application deadline—May 1st] BBBBB$662&,$7('(*5((Circle One.HWFK%HWKHO'LOOLQJ+RPHU.RW]1RPH6LWND9DOGH] [Application deadline—July 1st] BBBBB$662&,$7('(*5((/3151 $QFKRUDJH [Application deadline—May 1st and October 1st]

As of 2018, the BACCALAUREATE DEGREE (BS) application no longer requires letters of recommendation.

Applicant: Please mark appropriate program. Letters from relatives will not be accepted. Students are responsible for ensuring that the letters are received by the published deadline. Letters received after the deadline will not be accepted.

Your estimate of this applicant's suitability for admission to the School of Nursing is requested. Comments are considered confidential. Your cooperation in completing and promptly returning this form will assist both the applicant and the School.

Name of Applicant____________________________________________________________________________________ Last

First

MI

Previous Name(s)

1.

How long have you known the applicant and in what capacity?

2.

When were you last associated with the applicant?

3.

What do you consider to be the main qualities of strength and weakness of this applicant? If possible, give examples.

4.

Do you place full confidence in the applicant's integrity? __________ If not, please explain.

5.

In what community and health related activities has the applicant taken an active part?

Revised 1/22/18

6.

Does the applicant like to work with people? __________ What experiences has this applicant had which support your answer?

7.

Additional Comments:

Please indicate your endorsement of this applicant by checking one of the following: Highly Recommend_____

Recommend_____

Uncertain_____

Do Not Recommend_____

_______________________________________________________________________________________________ Signature Date _______________________________________________________________________________________________ Printed Name Position/Title Organization _______________________________________________________________________________________________ Printed address Email address Telephone number This letter of recommendation will be placed in the student's file and upon request will be made available to the student and faculty advisor for review. This letter will not be reproduced. Please return this form to:

Coordinator of Student Affairs School of Nursing 3211 Providence Drive, HSB 101 Anchorage, AK 99508

(907) 786-4550 Phone (907) 786-4559 Fax [email protected]

UAA School of Nursing 3211 Providence Drive, HSB 101 Anchorage, AK 99508 LETTER OF RECOMMENDATION UNDERGRADUATE NURSING PROGRAM

BBBBB$662&,$7('(*5(($$6 $QFKRUDJH [Application deadline—February 1st] BBBBB$662&,$7('(*5((Circle One-XQHDX.HQDL, Mat-Su [Application deadline—May 1st] BBBBB$662&,$7('(*5((Circle One.HWFK%HWKHO'LOOLQJ+RPHU.RW]1RPH6LWND9DOGH] [Application deadline—July 1st] BBBBB$662&,$7('(*5((/3151 $QFKRUDJH [Application deadline—May 1st and October 1st]

As of 2018, the BACCALAUREATE DEGREE (BS) application no longer requires letters of recommendation.

Applicant: Please mark appropriate program. If applying to both AAS and BS (Pre-Licensure), mark both programs. Letters from relatives will not be accepted. Students are responsible for ensuring that the letters are received by the published deadline. Letters received after the deadline will not be accepted.

Your estimate of this applicant's suitability for admission to the School of Nursing is requested. Comments are considered confidential. Your cooperation in completing and promptly returning this form will assist both the applicant and the School.

Name of Applicant____________________________________________________________________________________ Last

First

MI

Previous Name(s)

1.

How long have you known the applicant and in what capacity?

2.

When were you last associated with the applicant?

3.

What do you consider to be the main qualities of strength and weakness of this applicant? If possible, give examples.

4.

Do you place full confidence in the applicant's integrity? __________ If not, please explain.

5.

In what community and health related activities has the applicant taken an active part?

Revised 1/22/18

6.

Does the applicant like to work with people? __________ What experiences has this applicant had which support your answer?

7.

Additional Comments:

Please indicate your endorsement of this applicant by checking one of the following: Highly Recommend_____

Recommend_____

Uncertain_____

Do Not Recommend_____

_______________________________________________________________________________________________ Signature Date _______________________________________________________________________________________________ Printed Name Position/Title Organization _______________________________________________________________________________________________ Printed address Email address Telephone number This letter of recommendation will be placed in the student's file and upon request will be made available to the student and faculty advisor for review. This letter will not be reproduced. Please return this form to:

Coordinator of Student Affairs School of Nursing 3211 Providence Drive, HSB 101 Anchorage, AK 99508

(907) 786-4550 Phone (907) 786-4559 Fax [email protected]

UAA School of Nursing 3211 Providence Drive, HSB 101 Anchorage, AK 99508 LETTER OF RECOMMENDATION UNDERGRADUATE NURSING PROGRAM

BBBBB$662&,$7('(*5(($$6 $QFKRUDJH [Application deadline—February 1st] BBBBB$662&,$7('(*5((Circle One-XQHDX.HQDL, Mat-Su [Application deadline—May 1st] BBBBB$662&,$7('(*5((Circle One.HWFK%HWKHO'LOOLQJ+RPHU.RW]1RPH6LWND9DOGH] [Application deadline—July 1st] BBBBB$662&,$7('(*5((/3151 $QFKRUDJH [Application deadline—May 1st and October 1st]

As of 2018, the BACCALAUREATE DEGREE (BS) application no longer requires letters of recommendation.

Applicant: Please mark appropriate program. If applying to both AAS and BS (Pre-Licensure), mark both programs. Letters from relatives will not be accepted. Students are responsible for ensuring that the letters are received by the published deadline. Letters received after the deadline will not be accepted.

Your estimate of this applicant's suitability for admission to the School of Nursing is requested. Comments are considered confidential. Your cooperation in completing and promptly returning this form will assist both the applicant and the School.

Name of Applicant____________________________________________________________________________________ Last

First

MI

Previous Name(s)

1.

How long have you known the applicant and in what capacity?

2.

When were you last associated with the applicant?

3.

What do you consider to be the main qualities of strength and weakness of this applicant? If possible, give examples.

4.

Do you place full confidence in the applicant's integrity? __________ If not, please explain.

5.

In what community and health related activities has the applicant taken an active part?

Revised 1/22/18

6.

Does the applicant like to work with people? __________ What experiences has this applicant had which support your answer?

7.

Additional Comments:

Please indicate your endorsement of this applicant by checking one of the following: Highly Recommend_____

Recommend_____

Uncertain_____

Do Not Recommend_____

_______________________________________________________________________________________________ Signature Date _______________________________________________________________________________________________ Printed Name Position/Title Organization _______________________________________________________________________________________________ Printed address Email address Telephone number This letter of recommendation will be placed in the student's file and upon request will be made available to the student and faculty advisor for review. This letter will not be reproduced. Please return this form to:

Coordinator of Student Affairs School of Nursing 3211 Providence Drive, HSB 101 Anchorage, AK 99508

SCHOOL OF NURSING CONFIDENTIAL REQUIRED INFORMATION The following information is REQUIRED for Federal reporting purposes and to improve the ability of the School to compete successfully for grant funding. This information sheet will be separated from your application and used for statistical purposes only. The information provided will NOT BE USED in making admission decisions and will be kept confidential. However, applications lacking the required information will be considered incomplete and will not be considered for admission until the information is provided. PLEASE PRINT (OR TYPE) and CIRCLE ALL APPROPRIATE NUMBERS. Name______________________________________________________ SSN or SID #_________________________ Last

First

M I

Your current employment status: 1. Unemployed 2. Employed Part-Time

3. Employed Full-Time

4. Self-Employed

Source of income: 1. Employment

2. Student financial aid

3. Parent/Guardian

4. Other: ______________________

Highest education level (specify AREA OF STUDY for numbers 5 - 9): 1. Currently in high school 2. High school diploma

3. GED 4. Some college

5. Vocational school ____________________________ 8. Some graduate school _________________________ 6. 2-yr degree___________________________________ 9. Graduate degree______________________________ 7. 4-yr degree___________________________________ Current application:

BS Nursing Science _________ or AAS Nursing _______

Semester and year of current nursing application:

Spring

Summer or Fall

20____

To determine educational and economic disadvantaged status: 1. Did either parent or guardian graduate from a 4-year college before your 18th birthday? _____Yes _____No 2. Is your annual family income equal to or less than the amount shown in the table below? ______Yes

______ No

Annual Income - Number of Persons in Household $13,530 - 1 Person

$32,250 – 5 Persons

$18,210 – 2 Persons

$36,930 – 6 Persons

$22,890 – 3 Persons

$41,610 – 7 Persons

$27,570 - 4 Persons

$46,290 – 8 Persons

For family units of more than 8 members, add $4,680 for each additional member

OPTIONAL INFORMATION Federal law prevents our requiring the information requested below. However, having this information enables the School to compete more effectively for Federal grant funding; therefore, we request that you provide the information VOLUNTARILY. The information you elect to provide will be kept confidential and WILL NOT BE USED in making admission decisions. Further, your application will be considered to be complete even if you elect to withhold the information requested below. I. ETHNICITY: Hispanic or Latino ______ OR Not Hispanic or Latino _____ II. RACE: 1. American Indian (IN)

2. Alaskan Aleut (AA)

3. Alaskan Indian, Southeast (AS)

4. Alaskan Indian, Haida (AH)

5. Alaskan Indian, Athabaskan (AT)

6. Alaskan Indian, Other (AI)

7. Alaskan Indian, Tsimshian (AM)

8. Alaskan Indian, Tlingit (AK)

9. Alaskan Eskimo, Yupik(AY)

10. Alaskan Eskimo, Inupiat (AQ)

11. Alaskan Eskimo, Other (AE)

12. Alaskan Native, Other (AN)

13. Asian, (SI)

14. Black, non-Hispanic (BL)

15. Native Hawaiian or Pacific Islander (NH)

16. Other (OT)

17. White, non-Hispanic (WH)

Date of Birth_______________

Gender: _____ Female _____ Male US Citizen ____ Permanent Resident ____ Non US _____

I understand that the information on this form will be used for statistical purposes only. All statements made are true to the best of my knowledge. SIGNATURE______________________________________________________________ DATE__________________________ Revised 8/2016