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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.
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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]
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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.
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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:
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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.
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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.
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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
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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] .
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