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Youngstown City School DistrictCHOFFIN SCHOOL OF PRACTICAL NURSING200 East Wood StreetYoungstown, Ohio44503 (330) 744-8723Dear Potential SPN Student:To apply to Choffin School of Practical Nursing, please fill out the attached application and return the completedapplication along with your 75.00 testing/application fee.APPLICATION AND TESTING FEES ARE NON-REFUNDABLE AND MUST BE PAID EITHER BYCERTIFIED CHECK, MONEY ORDER, OR CASH (PLEASE DO NOT SEND CASH THROUGH THE MAIL).PERSONAL CHECKS WILL NOT BE ACCEPTED.It is important for you to know that placement for our program is NOT ALWAYS IMMEDIATE.Entry is based on a completed application, testing successfully, space availability, and eligibility based on the results ofcriminal background checks.Pre-entrance test scheduling is done based on space availability. Testing is scheduled once a month beginning in Septemberuntil the class is full. There are a limited number of test given each month. You will receive an admit card with your testingdate and location; and instructions on how to register for the test and a study guide. Please bring the admit card, your testidentification sheet and photo identification with you to the testing site. You are permitted to reschedule one time at nocharge after your originally scheduled date with at least 24 hours notice. Additional rescheduling will result in having to paythe testing fee againSome of the areas included in the test are: Basic Math Skills (fractions, decimals, percentages and algebra) and ReadingComprehension. Each applicant must pass the pre-entrance test according to the school’s admission policy as indicatedbelow. If you are not successful the first time you take the test, you may be eligible to re-test based on enrollment for theprogram and available seating for the next scheduled test. There is a 50.00 non-refundable fee to retest.Testing is held on the second floor of Choffin Career and Technical Center in room 225 from 4:30 p.m. to 9:00 p.m.Please arrive at least 15 minutes early. The testing room door closes promptly at 5:00 p.m. and no one will be admitted afterthat time. Please bring two (2) #2 pencils, and a photo identification. Provisions for assistance in taking the test are availableaccording to the American Disabilities Act.A pre-entrance test is required for entry into the program. The successful applicant must score at or above the currentnational program (Practical Nursing) average in Math and Reading. The national average is determined by the testingcompany.CALCULATORS WILL BE PERMITTED.IF YOU REQUIRE FURTHER INFORMATION, PLEASE CONTACT THE HEALTH PROFESSIONS OFFICE AT (330)744-8723.
Student NumberFor office use onlyYOUNGSTOWN CITY SCHOOLS - CHOFFIN SCHOOL OF PRACTICAL NURSINGApplication for AdmissionA 75.00 fee (non-refundable), must be submitted with application. Submit payment in the form of cash or a moneyorder (no personal checks accepted). Payable to: Youngstown City School District (with "Choffin School of PracticalNursing" in the memo line)Choffin School of Practical Nursing provides admission to all qualified applicants regardless of age, religion/creed,ethnic origin, marital status, race, gender/sex, veteran status or disability which does not interfere with attainment ofprogram objectives.PLEASE PRINT:Date(Last Name)(First Name)(Middle Name)(Other Name(s) on Transcript)NameAddress(Number & Street complete address)(City)(State)(Zip Code)Email(Social Security Number)Phone: ()Area CodeCounty:NumberPERSON TO BE NOTIFIED IN CASE OF EMERGENCY:(Name)PhoneRelationship(Area Code)(Number)(Number & Street complete address)(City)(State)(Zip Code)FOR OFFICE USE ONLYTEST DATEPASSEDFAILEDP.E.(Subject)REFERENCES:Personal referencesTRANSCRIPT:RequestedDate receivedRequested1.2.3.Date receivedOfficial High SchoolOfficial G.E.D.CollegeOtherWithdrew Application (date)ReasonIt is the policy of the Youngstown City Schools to offer educationalactivities, employment practice, programs, and services withoutregard to race, color, national origin, sex, religion, handicap or age.
Encircle only highest number ofSchool years completed:High School9 10 11 12COMPLETE NAME OF SCHOOLLast High School AttendedGraduateYesNoSchool Address (Number, Street, City, State, ZipGEDCollegeScore1 2 3 4Date (Year)EnteredDate (Year)GraduatedDate (Year)WithdrewStreet AddressCity,State,ZipStreet AddressCity ,StateZipGrade average in high school?School Attendance: A Good B C Average D PoorIf poor explainList most recent employer first:State work experience (please include Company Name and Supervisor with proper mailing address)TypeNAME OF EMPLOYER ADDRESS (Street, City, State, Zip Code)of Work/HrsDatesReason for LeavingHave you ever applied for or attended:Attendance DatesApplied Only1. A school of professional nursing Yes Noto 2. A school of practical nursing Yes Noto Name of SchoolAddress of SchoolStreetCityStateZipReason for Leaving:PERSONAL REFERENCES: PLEASE GIVE NAMES AND COMPLETE ADDRESSES of three persons: NOT FAMILY MEMBERS OR SIGNIFICANTOTHERS. Must include employer or former employer (If ever employed) others: teacher, co-worker, clergy, family physician,neighbor, landlord. PLEASE DO NOT PROVIDE PHONE NUMBERS, WE DO NOT CALL REFERENCES.1. Name AddressNumber and StreetOccupationCity, State, ZipHave known for years2. Name AddressNumber and StreetOccupationCity, State, ZipHave known for years3. Name AddressNumber and StreetCity, State, ZipOccupation Have known for year
I understand the following statements:Students must be able to perform ESSENTIAL FUNCTIONS of Choffin School of Practical Nursing curriculum as listed below:Minimal acceptable mental and physical qualifications of an applicant for the Program of Practical Nurse Education includethe following abilities:1.2.3.4.5.Frequent walking and working in a standing position;Lift and transfer patients up to 6 inches from a stooped position, then push or pull the weight up to 3 feet;Lift and transfer patients from a stooped to an upright position to accomplish bed to chair and chair to bed transfers;Physically apply up to 10 pounds of pressure to bleeding sites, or in performing CPR;Respond and react immediately to auditory instructions/requests/monitor equipment, and perform auditory auscultationwithout auditory impediment;6. Physically perform up to an eight to twelve hour clinical laboratory experience;7. Perform close and distance visual activities involving objects, persons, and paperwork, as well as discriminate depth andcolor perception;8. Discriminate between sharp/dull and hot/cold when using hands;9. Manual dexterity required for preparing and administering medications;10. Ability to read medication labels and patient records;11. Perform mathematical calculation for medication preparation and administration;12. Speak English clearly enough for most patients to understand, and understand the verbal communication of Englishspeaking patients;13. Communicate effectively in writing, using appropriate grammar, vocabulary, and word usage;14. Make appropriate decisions under stressful situations;15. Carry out procedures that prevent the spread of infection, e.g., frequent handwashing, using mask and gloves, etc.Applicants are responsible to determine their own eligibility in light of these qualifications, to identify to the school anyparticular accommodation they may need.Students with a disability who enter the program do so with the understanding they will be expected to meet courserequirements, with any reasonable accommodation that may be provided by the school.Requests for reasonable accommodation will be evaluated by the Nursing Faculty, Supervisor of Practical Nursing, andDirector/Principal of Career & Technical Education.
HOW DID YOU HEAR OF CHOFFIN SCHOOL OF PRACTICAL NURSING? Please check whatever applies:Referred by an IndividualAdvertisement - Radio TV BillboardFacebookChoffin WebsiteOtherTO ENABLE YOU TO SUCCESSFULLY COMPLETE THIS PROGRAM, WHAT CHANGES WILL BE NECESSARY FOR YOU TO MAKEIN YOUR LIFE?I understand the following statements:Completing an application for admission to Choffin School of Practical Nursing does not obligate me or the schoolin regard to my admission. My application will be submitted for review to the faculty that comprise the AdmissionsCommittee.TO HAVE THE OPPORTUNITY FOR NEEDED CLINICAL EXPERIENCES AND/OR BE HIRED FOR EMPLOYMENT, A CRIMINALRECORDS CHECK, DRUG SCREENING AND A DRIVING HISTORY REPORT WILL BE REQUIRED. CLINICAL EXPERIENCEAND/OR EMPLOYMENT MAY BE DENIED RELATED TO CRIMINAL RECORDS CHECKS, DRUG SCREENING RESULTS AND ANYVIOLATION OF THE FACILITIES DRESS CODE.IF YOU ARE ACCEPTED INTO THE PROGRAM, YOU WILL BE TAKING CARE OF PATIENTS WITH A VARIETY OF ILLNESSES,INCLUDING INFECTIOUS DISEASES.Anyone entering a pre-licensure nursing program will also be required to have a criminal records check for theOhio Board of Nursing (OBN) when applying for licensure in the State of Ohio HB327. NO APPLICANT WILL BE MADEELIGIBLE FOR THE LICENSING EXAMINATION (NCLEX-PN) WITHOUT THE REQUIRED CRIMINAL RECORDS CHECK BEINGCOMPLETED AND IN THEIR FILE AT THE OHIO BOARD NURSING AND CHOFFIN SCHOOL OF PRACTICAL NURSING.The Ohio Board of Nursing under Chapter 119 of the Revised Code may deny, revoke, suspend or placerestrictions on the license of persons convicted of a crime, felony, or misdemeanor. Any false information will void thisapplication. If already accepted into the program, immediate dismissal will result. This application will not beconsidered unless these statements have been read and signed by the applicant.Applicant’s signatureDateAUTHORIZATION FOR RELEASE OF INFORMATIONI hereby authorize and request that you release to Choffin School of Practical Nursing all information both oral and/orwritten regarding my records, character, conduct and performance.I further release you (Choffin) from all liability which may result from furnishing such information.Applicant’s signatureDate of SignaturePlease note: You will not be considered for admission unless this authorization is signed.Application Form #101Revised 6/98, 2/02, 12/05/, 6/13, 7/14, 8/15, 6/16, 8/16
Youngstown City School District CHOFFIN SCHOOL OF PRACTICAL NURSING 200 East Wood Street Youngstown, Ohio 44503 (330) 744-8723 Dear Potential SPN Student: To apply to Choffin School of Practical Nursing, please fill out the attached application and return the completed application along with your 75.00 testing/application fee.
