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Rogue Community College
2014/15 Nursing Program Application
For Fall 2015 Entry
STEP ONE: Complete the online portion of the application available at:
https://docs.google.com/spreadsheet/viewform?formkey=dGRIaHBCM1lXdnY4STlDY2dveE9kVFE6MQ
DO NOT submit the online portion of the form more than once. To verify whether you have
already submitted the online form, email your Name and RCC I.D. Number to:
[email protected]
STEP TWO: Complete, print, and sign the Checklist and Agreement Form and the
Prerequisite/Course Completion Chart. If applying for the work experience points, attach the
completed Work Experience Verification Form and proof of your current unencumbered
Oregon certification or licensure as a CNA, LPN, RT, EMT, Paramedic or service standing as a
Corpsman or Medic. If applying for military veteran points, include a photocopy of your
certified Form DD214 – Service 2, verifying your honorable discharge.
STEP THREE: Mail the printed forms along with the $80 non-refundable processing fee (check
or money order made out to Rogue Community College) in a sealed envelope (make sure a
complete return address including the applicant’s name is on the outside of the envelope) to be
received no later than the annual deadline of 5 p.m. on February 15, 2015. Note that since
February 15, 2015 is a Sunday and February 16 is a holiday when the College is closed, this
year applications will be accepted until 5 p.m. February 17, 2015, and must arrive at the
address below by that deadline.
Rogue Community College, Enrollment Services
Attention: Nikki Koenig, RVC-G
Nursing Application
114 S. Bartlett Street
Medford, OR 97501
2014/15 Nursing Program Application
Checklist and Agreement
(for Fall 2015 Entry)
_______________________________
Applicant Name
_______________________
RCC Student ID
___________________
Social Security Number
______________________________________________
Secure Email Address (Official notifications will occur by email. It is the applicant’s responsibility to
provide a secure email address and ensure the College and Nursing Program Secretary are notified
of any changes in email address.)
Applicant: You must complete and submit this checklist as part of your nursing application. Please
initial each statement below indicating that you have read, understand, and agree to the application
requirements for the RCC Nursing Program.
Initial each item below:
1. I have been officially admitted to RCC and have obtained my 7 digit RCC ID#.
2. I have already completed STEP 1 by submitting the online portion of my Nursing Program
Application.
3. I have previously submitted (and verified arrival of official transcripts at RCC) or have attached
sealed official college transcripts from ALL previously attended, regionally accredited colleges
or universities including all coursework completed through Fall Term 2014. I understand my
application may be disqualified if I do not submit such transcripts. (Rogue Community
College transcripts do not need to be attached.)
4. I understand that a minimum of 30 credits of prerequisites must be completed with a C or
better by the end of Fall Term 2014 (with a minimum cumulative GPA of 3.0), including BI231
Anatomy & Physiology I with lab and MTH95 or higher level math course (or equivalent
transfer courses), in order to be eligible to apply.
5. For International students only: See Enrollment Services for admissions and registration
information.
6. I understand that if my points qualify me for Phase 2 as one of the top 85 applicants, I will
receive an email from the Nursing Program and need to respond to reserve a seat at the April
17 or 18 essay session in the computer lab on the Redwood Campus. If I have not received
notice of my status (i.e. whether I am among the top 85 applicants or among those who do not
make it to Phase 2) by April 10, 2015, I will call the Nursing Program at 541-956-7308.
7. I have provided a secure email address on my application and give my permission for RCC to
contact me through this email address. I understand I will be emailed a notice verifying receipt
of the application packet I am submitting to RCC and that I will also receive notification of my
Degree Audit results through email once it has been completed. I also understand that each
applicant will be notified by email of his/her status regarding acceptance by June 1, 2015. I
also understand that I am not to call the Nursing Program or Enrollment Services regarding
acceptance status unless so directed.
8. I understand that although co-admitted to the Oregon Health & Science University School of
Nursing, if I choose to transition from the Rogue Community College Nursing Program to
OHSU, I will have to undergo a Criminal Background Check for OHSU at the time of transition
and my ability to enroll in OHSU courses may be negatively impacted by any criminal history in
my background.
9. I understand that if I have a financial hold on my RCC account, my application will be
disqualified unless the financial hold is removed before 5 p.m., February 17, 2015.
10. I understand to earn selection points for being a military Veteran I must attach proof of my
honorable discharge (Photocopy of my Certified Form DD214 – Service 2).
11. I understand to potentially earn selection points for work experience (only as a CNA, LPN, RT,
EMT, Paramedic, Medic, or Corpsman), I must attach a completed Work Experience
Verification Form and proof of my current certification or licensure as a CNA, LPN, etc. (Medic
or Corpsman work experience documentation should indicate standing at the time of service.)
12. I have completed and attached the Prerequisite/Course Completion Chart.
13. I have attached the $80 non-refundable nursing application processing fee (check or money
order made payable to Rogue Community College).
14. I understand that any documents submitted, but not requested by this application form (e.g.
letters of reference) will be discarded/shredded.
15. I understand that reading and following directions is critical to success in any nursing program.
Incomplete applications (e.g. not completing admission to Rogue Community College, lack of
student ID number in places where ID number is called for, lack of application fee, lack of
submission of Official transcripts to Enrollment Services, lack of signature, etc.) will result in
disqualification and that disqualified applicants will only receive notice of such after the
application deadline has passed.
16. I understand applications will be accepted beginning September 29, 2014, even though fall
courses have not yet been completed. I understand it is my responsibility to make sure that all
required application materials are received in the RCC Enrollment Services Office (or
postmarked) no later than 5 p.m. on February 17, 2015.
17. I have read and I understand the program information and admission criteria (including
requirement for negative urine drug screen and criminal history background check in order to
be admitted) for the nursing program at RCC. Program information, including selection points,
may be found at: http://go.roguecc.edu/department/nursing/adn-program.
18. I understand that if accepted I will be required to order a criminal history background check
with the RCC Nursing Department’s contracted agency which performs criminal history
background checks and must self-disclose any pertinent history prior to admission and must
disclose any warrant, arrest, citation, charge or conviction if such occurs after admission.
19. I understand that a history of certain crimes might result in my being deemed “not approved”
for the program.
20. I understand that by making application to the Rogue Community College Nursing Program I
am also applying for co-admission and authorizing the release of my application and academic
information to OHSU as needed to facilitate my program of study or financial aid or for
statistical or evaluative purposes
21. I give my permission for release of pertinent application and academic information to the
OCNE partner schools, including OHSU as needed to facilitate my program of study or
financial aid or for statistical or evaluative purposes. In addition, I am authorizing release of
my information to the Oregon Center for Nursing and the Oregon State Board of Nursing for
statistical and research purposes only.
22. I understand that it is my responsibility to meet all program and application criteria. RCC staff
are available to answer application related questions, but will not check my application for
completeness prior to submission.
23. I verify that all statements on this application are complete and true and I understand that
falsification of any information may lead to disqualification or dismissal from the program.
_______________________________
Applicant Signature
_______________________
RCC Student ID
___________________
Date
In compliance with state and federal laws, Rogue Community College does not discriminate on the basis of
race, religion, color, national origin, age, gender or disability in employment, or in any of its educational
programs, or in the provision of benefits to students. For information about Rogue’s policy of nondiscrimination, contact the Title IX coordinator at (541) 956-7003 or the Section 504 coordinator at
(541) 956-7213. In addition the nursing program adheres to the Oregon State Board of Nursing rules, which
prohibit discrimination in selection and progression of students based on sexual preference or marital status.
l
Rogue Community College – Nursing Program
Prerequisite/Course Completion Chart
Student Name/ID #: _________________________________________
Provide the requested information for courses that you have already completed, or plan to complete. To be eligible to apply, you must have
completed a minimum of 30 credits of the required prerequisite/preparatory coursework including MTH95 or higher and BI231 (or equivalent
within the past 7 years) with a cumulative application GPA of at least 3.0 prior to the application deadline. For calculation of your application GPA,
your most recent grade in a course will be used. Exception: If you have completed more than one math, computer science or required elective
course that would equally apply to a requirement, the course with a higher grade will be used. If you are accepted to the program, all prerequisite/
preparatory courses (minimum of 46 credits) must be completed with a “C” or better by the end of summer term in order to retain acceptance.
Required Prerequisite/Preparatory Courses
RCC Course Number/Title
Your Completed or
Planned Course #
College & Year Course Completed
(or planned course)
CS120 Concepts in Computing (or documented
proficiency within 10 years)
Grade
(if complete)
RCC
Credits
0-4
BI211 General Biology I w/lab (including genetics)
4
BI231 Anatomy & Physiology I (within 7 years)
4
BI232 Anatomy & Physiology II (within 7 years)
4
BI233 Anatomy & Physiology III (within 7 years)
4
MTH95 (or 93 & 94) Intermediate Algebra or higher
4
NFM225 Nutrition
4
*PSY201 or 202 General Psychology I/II (or other 3-4
credit Social Science if PSY215 requirement has
been met.
*4
PSY215 Lifespan Human Development
4
*WR121 English Composition I
*4
*WR122 English Composition II
*4
**Social Science Elective
3
***Humanities, Social Science, or Science Electives –
(Will only be applied as needed to meet minimum of
46 prerequisite/preparatory credits)
0-6
*3 credit courses completed before Summer 2009 are acceptable to meet these prerequisites.
**See the College Catalog for a list of acceptable Social Science courses that meet this requirement for the AAS degree.
***Most applicants will not require additional credit in this elective area to meet the 46 credit prerequisite requirement. See the College Catalog
for a list of acceptable Social Science, Humanities, and Science courses. This elective area may also include 100 level or higher foreign language,
speech, or extra credits when a 4 or 5 credit course has been used to meet a 3 credit requirement.
Possible Additional Selection Point Items
Please Circle
Your Response
Additional Information
I have previously earned an Associate’s Degree or
higher at a regionally accredited College/University.
YES
NO
Highest Degree Completed:
YES
NO
Term/Year Completed:
YES
NO
Number of in-program elective
credits completed:
YES
NO
YES
NO
YES
NO
YES
NO
I have previously completed BI234 Microbiology w/lab
(or equivalent) with a “C” or higher grade.
I have completed at least 8 credits of in-program
electives as listed on the Nursing Graduation Guide.
I have repeated BI231 or BI232 or BI233 at least once
in the past 7 years. (W & AU attempts count as repeats)
I am a military veteran and have submitted my DD214
as proof of my honorable discharge from the service.
I have submitted the signed Work Experience Form
verifying at least 400 hours of work experience as a
CNA, LPN, RT, EMT, PARAMEDIC or Medic/Corpsman
I am a current resident of Josephine or Jackson County
Completed at (School Name)
WORK EXPERIENCE VERIFICATION - CNA, LPN, RT, EMT, PARAMEDIC or MEDIC/CORPSMAN
Rogue Community College – Nursing Program
2014/15 Application for 2015 Fall Entry
Student Name:
Date: _________________
Dear Employer/Supervisor/Human Resources Manager:
The above individual is planning to apply to the RCC Nursing program by the February 2015 deadline. To earn
three points in the selection process, the applicant must prove accumulation of a minimum of 400 hours work
experience since February 1, 2014 in any of the above (and only the above) roles and hold current
certification or licensure. [Note: Veterans who served as a medic or corpsman must prove 400 hours of
experience in that role since February 1, 2011.] To assist this applicant with the process, please fill in the
requested information, seal this form in an envelope (preferably a company letterhead envelope) and
sign your name across the seal. The applicant may submit documents from more than one employer in order
to provide proof of required hours of work experience.
The applicant must attach the sealed envelope to the application and submit it no later than 5:00 p.m. on
February 17, 2015 to be eligible for the points. If you have any questions you may call me at (541) 956-7308.
Thank you for your help.
Sincerely,
Linda Wagner, RN, MN
Nursing Department Chair
Can you verify that this applicant has worked as a CNA, LPN, RT, EMT, PARAMEDIC, MEDIC or CORPSMAN
for >400 hours at your facility in the time frame given above?
Yes ____
No ____
Total Number of Hours Worked here as: [_______________________] =________
Insert role
Total hours
_______________________________
Signature of Supervisor, HR Manager, or
Commanding Officer
_____________________________
Printed Name and Title
_________________________________
Facility
_____________________________
Phone Number