application for admission - lipper scholarship
Transcription
application for admission - lipper scholarship
APPLICATION FOR ADMISSION - LIPPER SCHOLARSHIP PLEASE READ: the following are important instructions explaining how to complete and save this application. Complete the application below in Adobe Acrobat Reader. You will not be able to save your responses if you complete it in your web browser. Questions marked * are required. Please contact Zach Turner at +1 (617) 874-4788 or [email protected] if you have any questions or concerns. Instructions for submitting your completed application with the required attachments are on the last page of this document. PERSONAL INFORMATION Identification Name* Select one Prefix Select one First Name Middle Name Have you ever used another name (such as a maiden name?) * Last Name Yes Suffix No Other name* Select one Select one Prefix First Name Middle Name Last Name Suffix What is your date of birth? * MM/DD/YYYY Contact Information Current Address * Will this be your address during the program? Street Address Apartment # City State/Province/Region Country/Territory Postal Code Permanent Address* Will this be your address during the program? Check here if the same as current address Street Address Apartment # City State/Province/Region Country/Territory Postal Code Telephone/Fax/Email * Please include country and area codes. Primary Telephone # Alternate Telephone Number Preferred E-mail address Application is continued on next page. Alternate E-mail Address Fax Yes No Yes No APPLICATION FOR ADMISSION - LIPPER SCHOLARSHIP CONTINUED Demographic and Background Information Are you a US citizen? * Yes No Are you a permanent resident (green-card holder) of the U.S.? Yes No Are you a veteran of the United States military? Yes No If no, what is your country of citizenship? To meet federal requirements on the collection and reporting of race/ethnicity, please answer the following questions. These questions are optional and any response will not affect the admission decision. Do you consider yourself Hispanic / Latino(a)? What is your race? American Indian or Alaska Native Black of African American White Yes No Yes No Asian Native Hawaiian or Other Pacific Islander Have you ever been convicted of a misdemeanor or a felony? If yes, please list type, date and outcome of offense. You may be contacted by Simmons staff for additional information. LANGUAGE INFORMATION Language Fluency Is English your native language? * Yes No If no, please list your native language: Are you fluent in languages other than English? Please list them: TOEFL Score The Test of English as a Foreign Language (TOEFL) is required of all applicants whose first language is not English. The TOEFL is not required if the applicant has earned either a bachelor’s or master’s degree from a regionally accredited U.S. post-secondary institution or at a post-secondary institution recognized by the Ministry of Education in an English-speaking country. TOEFL Format: Select one TOEFL Score: Date Taken: A minimum TOEFL score of 550 (paper-based) or 230 (computer-based) or 88 (internet-based) is required. Official score results must be sent directly from Educational Testing Service (ETS) to Nursing@Simmons Admissions. Mail score results to: Simmons School of Nursing & Health Sciences 8201 Corporate Drive, Suite 900 Landover, MD 20785 Simmons College Reporting Code is 3761. Application is continued on next page. Page 2 of 9 APPLICATION FOR ADMISSION - LIPPER SCHOLARSHIP CONTINUED PROGRAM INFORMATION I am applying to the MSN (Advanced Practice Nurse) program.* To which term are you applying? * Select one On what basis would you like to take classes? * Full-Time Part-Time Full-Time is defined as 8-11 credits per term. Part-Time is defined as 6-8 credits per term. Are you a graduate of Simmons College? * Yes No If you have previously attended Simmons College, please list program name(s) here. Program 1 Program 2 Program 3 Please list any relatives who have graduated from Simmons College. Relative 1 Graduation Date (mm/yyyy) Relative 2 Graduation Date (mm/yyyy) Relative 3 Graduation Date (mm/yyyy) ACADEMIC BACKGROUND Colleges/Universities Attended It is required that you include any secondary or postsecondary institution in which you attended classes. If you went to multiple institutions, please enter each separately. All post-secondary institutions must be recognized by the Ministry of Education in the institutions home country. Official transcripts/credentials must be translated and evaluated by an evaluation service such as the World Evaluation Service (WES). Official transcripts must be sent to the Nursing@Simmons Admissions Office: Simmons School of Nursing & Health Sciences 8201 Corporate Drive, Suite 900 Landover, MD 20785 United States of America All submitted materials, including transcripts, must be in English. If you include any secondary or postsecondary institution which does not provide transcripts in English, you must submit them through an approved evaluation service. If you have questions about obtaining a proper evaluation, please contact Zach Turner at +1 (617) 874-4788 or [email protected] Application is continued on next page. Page 3 of 9 APPLICATION FOR ADMISSION - LIPPER SCHOLARSHIP CONTINUED College/University 1 Institution Name State/Province/Region Country Attended from (MM/YYYY) Graduation Date (if applicable, MM/YYYY) Degree Major Did you graduate from this institution? * Yes No Currently Attending Degree level* Select one College/University 2 Institution Name State/Province/Region Country Attended from (MM/YYYY) Graduation Date (if applicable, MM/YYYY) Degree Major Did you graduate from this institution? * Yes No Currently Attending Degree level* Select one College/University 3 Institution Name State/Province/Region Country Attended from (MM/YYYY) Graduation Date (if applicable, MM/YYYY) Degree Major Did you graduate from this institution? * Yes No Currently Attending Degree level* Select one If you need more space, please attach with your submitted application. Application is continued on next page. Page 4 of 9 APPLICATION FOR ADMISSION - LIPPER SCHOLARSHIP CONTINUED When did you graduate high school? (MM/YYYY) * Have you previously been dismissed or had your candidacy terminated from an academic institution/program? Yes No Yes No Yes No If yes, please specify: Additional Questions Have you received or are you in process of receiving your Bachelor of Science in Nursing (BSN) or a Bachelor's degree in a non-Nursing discipline? * Do you currently hold or are you in the process of receiving an active Registered Nurse (RN) license? * If yes, please provide the following information: From which country/state/province is your active RN license? In Progress (please only list a foreign license if you hold a license from outside of the United States) Please provide your name exactly as it appears on your RN license. What is your active RN license number? (please only list one if you hold multiple licenses) Have you ever had your nursing license suspended, revoked, or in any way restricted by an institution, state or locality? Yes No If yes, Please list the reason, date, and location of the infraction. Please list any nursing-related certifications (ex. ACLS) you hold. ___________________________________________________________________________________________ _ EXPERIENCE CLINICAL What is your current RN specialty? Select one How long have you been in your current specialty? Select one Please select all the care settings in which you have worked. Family Practice Pre-Op Testing Hospital-based Clinic Other Pediatric Practice Student Health Clinic Employee Health Department Internal Medicine Practice School-based Clinics Federally-funded Healthcare Center If other, please describe: Application is continued on next page. Page 5 of 9 APPLICATION FOR ADMISSION - LIPPER SCHOLARSHIP CONTINUED If you have spent time shadowing a Nurse Practitioner, in what setting was it? Select all that apply. Family Practice Pre-Op Testing Hospital-based Clinic Other Pediatric Practice Student Health Clinic Employee Health Department Internal Medicine Practice School-based Clinics Federally-funded Healthcare Center If other, please describe: In a statement of approximately 250 words, describe your experience working with families within the healthcare system. * Please add any additional information regarding your clinical skills that you would like to share with the Admissions Committee. RECOMMENDATIONS MSN applications require three (3) Letters of Recommendation which should be provided by: • A clinical supervisor or nurse manager who has direct knowledge of your skills in the clinical setting and how they will translate into the Advanced Practice Nurse role, • A professor, faculty member, or academic advisor who can provide a meaningful assessment of your academic record. If you have been out of school for five years or more, a nurse educator or clinical instructor can be supplemented for the academic recommendation, and • A practicing clinical nursing professional, APRN, who has served as a mentor and can speak to your abilities as a nurse and your potential to become a Advanced Practice Nurse. Please complete the information on the next page and ensure that the contact information is accurate. The Nursing@Simmons admissions team will contact your recommender with instructions for providing a letter of recommendation. Application is continued on next page. Page 6 of 9 APPLICATION FOR ADMISSION - LIPPER SCHOLARSHIP CONTINUED Recommender 1 First Name Last Name Email address (required) Phone number (with country and area code) Employer (optional) Job Title (Optional) Relationship to you Would you like to waive your right to examine this letter of recommendation? * Yes No Under the Family Educational Rights and Privacy Act of 1974, students have access to their education record, including letters of recommendation. However, students may waive their right to see letters of recommendation, in which case the letters will be held in confidence. Recommender 2 First Name Last Name Email address (required) Phone number (with country and area code) Employer (optional) Job Title (Optional) Relationship to you Would you like to waive your right to examine this letter of recommendation? * Yes No Under the Family Educational Rights and Privacy Act of 1974, students have access to their education record, including letters of recommendation. However, students may waive their right to see letters of recommendation, in which case the letters will be held in confidence. Recommender 3 First Name Last Name Email address (required) Phone number (with country and area code) Employer (optional) Job Title (Optional) Relationship to you Would you like to waive your right to examine this letter of recommendation? * Yes No Under the Family Educational Rights and Privacy Act of 1974, students have access to their education record, including letters of recommendation. However, students may waive their right to see letters of recommendation, in which case the letters will be held in confidence. Application is continued on next page. Page 7 of 9 APPLICATION FOR ADMISSION - LIPPER SCHOLARSHIP CONTINUED ESSAYS AND RESUME/CV Resume Your resume/curriculum vitae should include: • • • • • Educational background including institutions, degree(s) awarded, degree(s) in progress, dates of degree(s) awarded, and/or anticipated date of receiving degree(s). Relevant employment history, including: o Job title (including unit), job description, and relevant duties performed. o Employment dates of each position. Community service or volunteer experience. Any awards, publications, presentations, and memberships. Evidence of leadership and career progression. This is an application requirement. Please attach your resume/curriculum vitae to your submitted application. Allowed file types are .doc, .docx, .gif, .html, .jpg, .jpeg, .pdf, .png, .rtf, .tif, .tiff, .txt Statement of Purpose Please submit a one to two page essay discussing the following: • • • Your career goals. How your specific clinical experiences have prepared you for the Advanced Practice Nurse role. Why Nursing@Simmons is the best fit for you and how the program will assist you in reaching your professional and educational goals. This is an application requirement. Please attach your statement of purpose to your submitted application. Allowed file types are .doc, .docx, .gif, .html, .jpg, .jpeg, .pdf, .png, .rtf, .tif, .tiff, .txt Optional Statement To get a more complete picture of your academic and/or personal background to best inform the admissions committee’s review of your application, you are welcome to attach an addendum explaining any of the following: • • • • • • An exception in your academic performance for resulting in a lower grade point average than the rest of your academic career; An overall grade point average that does not reflect your true abilities; A gap in your college attendance; An incomplete or significant change in your course of study or institution; A family/personal circumstance that influenced your academic performance; A disciplinary history This submission is optional. Please attach optional statement to your submitted application. Allowed file types are .doc, .docx, .gif, .html, .jpg, .jpeg, .pdf, .png, .rtf, .tif, .tiff, .txt Application is continued on next page. Page 8 of 9 APPLICATION FOR ADMISSION - LIPPER SCHOLARSHIP CONTINUED CERTIFICATION AND SIGNATURE Before submitting this application, please be sure that you have carefully reviewed your responses and that you have answered all of the questions accurately. Your responses will become the official property of Simmons College, and your admission will be based on the answers you have provided. You cannot change your answers through this form once they are submitted. Please contact your Admissions Counselor if you need to update your application record after submitting. Additionally, please review the Simmons College Terms of Service before submitting. Digital Signature I hereby attest that the information contained in this application and in any supplemental materials which I submit, is complete, factually accurate, and honestly presented as of the date submitted. I have reported all post-secondary attendance and have submitted all required educational documents. I further assert that this material is for the sole use of Simmons College in determining my suitability for admission. I understand that the application materials become property of Simmons College and cannot be returned to me. Upon my acceptance and matriculation, I am subject to the academic rules and regulations of Simmons College and to the ethical standards and conduct as a student. I understand that any misrepresentation by me will be cause for withdrawal of my application, denial of admission or revocation of admission and enrollment. Full Name Date I have read and agree to the Simmons College Terms of Service. INSTRUCTIONS FOR SUBMISSION Please save this PDF and email your completed application with any attachments to [email protected]. Please ensure that your attachments are clearly labeled and in one of the acceptable file formats (see above). Your final submission should include the following: • • • • • This application Your resume or curriculum vitae Your Statement of Purpose Your optional statement if you chose to provide one Addenda to the Colleges and Universities section if you ran out of space In order to be considered for admissions, your file must be complete and the following applications items must be received separately from your submitted application form: • Official transcripts (with evaluations/translations, if appropriate). These must be received directly from the school (or from the service providing the translation) • Letters of recommendation provided directly by the recommenders listed in this application. All materials must be submitted in English. If you have any questions or concerns, please contact Zach Turner at +1 (617) 874-4788 or [email protected] . Page 9 of 9