Nursing Online Application

Semester Applying

Year Applying

Contact Information

* Full Name

* Street Address

Street Address Line 2

* City

* State or Province

* Postal or Zip Code

* Phone Number

* Email Address

Date of Birth

Previous Education

* High School Attended

* County you currently reside in

* Have you Previously Attended an Area Technical Center

YesNo

* Gender

MaleFemalePrefer Not to Answer

If you have previous Healthcare experience please describe

* Present Educational Status

GEDHigh SchoolPrevious or Current College

College Attended if Any

ACT Information

* Have you Taken the National ACT?

YesNoPlanned

If planned what date

Educational Track

* Educational Track

ADNBridgePractical NursingBoth ADN and Practical Nursing

* Have you Previously Attended a Nursing Program?

YesNo

If you have previously attended a nursing program, when, where and reason for leaving:

If You Are Applying for the Bridge Program

LPN License Number

If Yes, Number of Years Employed as LPN

If Employed as LPN, Where?

Medical Nurse Aid Section, Choose All That Apply

* On Kentucky Medicaid Nurse Registry

YesNo

Completed Medicaid Nurse Aide Course

YesNo

I anticipate taking the CNA Course at

On this date

By submitting this form, you agree that the information submitted is truthful and accurate.

* I agree

YesNo