Practical Nurse Application

Nursing Application for LPN Program

Comments
This field is for validation purposes and should be left unchanged.
Personal Information
Please select one:*
Crowder College currently offers the Practical Nurse program at two locations. Please select the one you plan to attend.
- McDonald County
- Nevada
Name*
First Middle Last
Birth Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Crowder Student ID Number*
Social Security Number*
Email*
Enter Email Confirm Email
Phone Number*
Alternate Phone Number*
Are you a US Citizen?*
- Yes
- No
Have you ever been convicted as an adult offender for any crime, including DWI or DUI?*
- Yes
- No
Licensures or Certifications*
- CNA
- CMA
- RMA
- EMT
- Paramedic
- CPR
- Other
Please mark all licensures or certifications that you have in the medical field:
If "Other", please specify.
Education
List high school or GED and colleges Attended
Name of School*
Address of School*
Street Address City State
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Degree or Hours Earned*
Add a Second School
- Yes
- No
Education
List high school or GED and colleges Attended
Name of School*
Address of School*
Street Address City State
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Degree or Hours Earned*
Add a Third School
- Yes
- No
Education
List high school or GED and colleges Attended
Name of School*
Address of School*
Street Address City State
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Degree or Hours Earned*
Transcripts
I have requested all official transcripts to be sent to Crowder College Records Department*
- Yes
- No
Occupational Experience
List all employment within the past 5 years, start with the last date of employment (Employers may be contacted as references)
Employer
Employer Address
Street Address City State
Employer Phone Number
Type of Employment
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Add a Second Employer
- Yes
- No
Occupational Experience
List all employment within the past 5 years, start with the last date of employment (Employers may be contacted as references)
Employer*
Employer Address*
Street Address City State
Employer Phone Number
Type of Employment*
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Add a Third Employer
- Yes
- No
Occupational Experience
List all employment within the past 5 years, start with the last date of employment (Employers may be contacted as references)
Employer*
Employer Address*
Street Address City State
Employer Phone Number
Type of Employment*
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Describe a positive contribution you would bring to the Crowder learning environment.*
Community service completed in the last 5 years, please include date and description of service.
References
Please list the names, phone numbers, and email addresses of three persons (not relatives or friends) who can evaluate your aptitude for the nursing profession. Recommended references include supervisors, coworkers, college instructors, etc… (Employers who can speak to work ethic are often a good option.) Reference questionnaires will be delivered by email to the references indicated below. You will be notified by email when each of your references completes their questionnaire.
First Reference Name*
First Last
First Reference Phone Number*
First Reference Email*
Enter Email Confirm Email
Second Reference Name*
First Last
Second Reference Phone Number*
Second Reference Email*
Enter Email Confirm Email
Third Reference Name*
First Last
Third Reference Phone Number*
Third Reference Email*
Enter Email Confirm Email
Acknowledgements
Acknowledgement 1*
Yes I Understand
I do hereby certify that the above information is complete and correct to the best of my knowledge under penalty of perjury.
Acknowledgement 2*
Yes I Understand
I understand that any question answered in a false manner will result in the application being void and
therefore not considered. I understand that I will not be considered for admission into the nursing
program until I have completed the application process as outlined in the application information sheet.
“The Family Educational Rights and Privacy Act of 1974”, Public Law 93-380 as amended and signed into law by President Ford on December 31, 1974, states that enrollees have the right to examine confidential files. It also states that they may waive this right if they do so desire.

The law provides that references may be either confidential or non-confidential at the option of the registrant. The registrant has the option to inspect the references in a non-confidential file.

Confidential references are those which the registrant has waived the right to see.

Please consider the following in making a decision to have confidential or non-confidential references.

1. School officials prefer to see confidential references, believing the references are more frank in such credentials. The limited number of studies which have been made of confidential vs. non-confidential references Indicate a preference of both hiring officials and college faculty for confidential or enclosed references.

2. Registrants should be most selective in asking persons to write references for them. The persons selected should know the registrant well and be able to state facts and competencies of the registrant.

3. Writers of references will be informed at the time of writing that the reference is confidential or that the registrant will be permitted to see the reference.
I Have Elected:*
- A Confidential File
- A Non-Confidential File
Comments/messages for the application committee regarding your application?
How Did You Hear About Us?
- crowder.edu
- School Counselor
- Current Crowder Student
- Crowder Alumni
- Social Media
- Employer
- Friends or Family
- Crowder Faculty
- Google
- Other
If you selected other, please provide more information.
By execution of the application, I do hereby authorize Crowder College or it’s representatives to verify all information contained within this application, and do waive any privilege I may have as to confidentiality to Crowder College or it’s representatives, and I do authorize any agency – – educational, health, or law enforcement – – to furnish to Crowder College or it’s representatives the information necessary to validate the information contained upon my application to the Nursing Department.
Signature*
Type in full name to sign and affirm this application
Date Signed*
Month
Day
Year
Thank you for your interest in Crowder’s Practical Nursing Program.

If you have any questions or difficluty uploading files call 417-667-0518 ext. 5238 or email NursingNevada@crowder.edu or NursingMcdonaldCounty@crowder.edu
Please attach transcript (required)
Max. file size: 50 MB.

Accepted file types: doc, docx, jpg, pdf

.
Please attach TEAS score to this field (required)
Max. file size: 50 MB.

Accepted file types: doc, docx, jpg, pdf

.
Please attach Family Care Safety Registry to this field (required)
Max. file size: 50 MB.

Accepted file types: doc, docx, jpg, pdf

.
Please attach any Medical Certification to this field (optional)
Max. file size: 50 MB.

Accepted file types: doc, docx, jpg, pdf

.
Please attach any Medical Certification to this field (optional)
Max. file size: 50 MB.

Accepted file types: doc, docx, jpg, pdf

.
Please attach any Medical Certification to this field (optional)
Max. file size: 50 MB.

Accepted file types: doc, docx, jpg, pdf

.
Please attach any other supporting documents (optional)
Max. file size: 50 MB.

Accepted file types: doc, docx, jpg, pdf

.
Please attach any other supporting documents (optional)
Max. file size: 50 MB.

Accepted file types: doc, docx, jpg, pdf

.
The Family Care Safety Registry may be accessed at https://health.mo.gov/safety/fcsr/

For additional information please see the Nursing Student Handbook and the Missouri Revised Statutes Chapter 335 Section 335.066.1.

How to Get Started

Start Here

Ways to Pay

Learn More

Find Your Program

Programs

Academic Resources

Other Services

Get Involved

Find Resources

Get Involved

Live on Campus

Ways to Give

EMPLOYMENT OPPORTUNITIES

Foundation & Alumni

Training & Grant Programs

Who We Are

Our Values

About Us

Organization

How to Get Started

Start Here

Ways to Pay

Learn More

Find Your Program

Programs

Academic Resources

Other Services

Get Involved

Find Resources

Get Involved

Live on Campus

Ways to Give

EMPLOYMENT OPPORTUNITIES

Foundation & Alumni

Training & Grant Programs

Who We Are

Our Values

About Us

Organization

Practical Nurse Application

Nursing Application for LPN Program

Personal Information

Education

Education

Education

Transcripts

Occupational Experience

Occupational Experience

Occupational Experience

References

Acknowledgements

Thank you for your interest in Crowder’s Practical Nursing Program.