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RCCROGUE COMMUNITY COLLEGERogue Community CollegeLPN/RN Advanced Placement AgreementMust be emailed to 2021AdvancedPlacemen@roguecc.edu. Your name and RCC ID# must be in the subject line. Pleaseprint neatly if you choose to complete by hand:Last NameFirst NameFull Middle NamePrevious Last Name(s)Social Security NumberRCC Student ID NumberEmail addressNotify Administrative Assistant (Melissa Weast) at mweast@roguecc.edu of ANY address, email, or name change after you submityour applicationInitial each item below to acknowledge you have read, understand, and agree to the following:1. I have completed the Rogue Community College admission process and have obtained an RCC ID or I am acurrent student with RCC ID. (If not already admitted to RCC, the RCC general college admission application isavailable on the college website.)2. I understand that by making application to the Rogue Community College Nursing Program LPN AdvancedPlacement I am also applying for co-admission to OHSU and authorizing the release of my application andacademic information to OHSU as required to facilitate my program of study or for statistical or evaluativepurposes.3. I understand that the application process is to be done electronically and I may NOT mail nor drop off myapplication, transcripts, or verification documents unless I have in my possession official, sealed transcripts ofwhich I may mail USPS to the Grants Pass location of: Rogue Community College, Attn: Registrar, 3345Redwood Highway, Grants Pass, OR 97527.4. I understand that by emailing my application, agreement, and verifications that I am able to confirm receipt and/orattachment of verifications by checking my sent email and/or receipt of email by sending my email return/receiptnotification.5.I must provide transcripts of a completed Practical Nursing Program as well as college transcripts from anyregionally accredited university or college previously attended and for all prerequisite and program generaleducation courses that have been completed prior to October 15, 2021 and understand I will not be eligible forpoints awarded for non-repeat of A&P if I do not submit such transcripts. (Rogue Community Collegetranscripts do not need to be attached.)6.I have attached the LPN Advanced Placement Prerequisite and Other General Education Completion Chartindicating that I have completed all nursing program prerequisites and general education electives (minimum of45 credits) with a minimum grade of C or better and a minimum cumulative GPA of 3.0. My required computerscience course or proficiency exam is no older than 10 years and my anatomy and physiology courses will not beolder than 7 years by October 2021.7.I have attached the LPN Work Experience Form verifying at least 500 hours of work experience as an LPN.8.I understand any additional documentation that I upload and attached not requested in this application will bediscarded/shredded.9.I understand that if admitted to the advanced placement program that I will need to register for NRS230Pharmacology and NRS231 Pathophysiology courses winter term. Completion of those courses will allowregistration for Pharmacology II, Pathophysiology II, and NRS115/115C in spring.10. I understand that the RCC Nursing Program, in agreement with other Consortium partners, has a policy thatstates “Students who have failed (or withdrawn while failing) any nursing course more than once (or any twonursing courses), regardless of the program, will not be considered for re-entry or admission to the program,” and4

Student Name:RCC ID:failure of any two pharmacology and/or pathophysiology or other nursing courses will also eliminate me fromadvanced placement or other Nursing Program opportunities at RCC.11. I understand that if I progress satisfactorily to spring term courses, that I will be required to abide by the OregonHealth Authority Chapter 409, Division 30 Rule as it applies to all healthcare students enrolled in higher educationprograms in the State of Oregon and will be required to submit and pass the criminal history background checkand a urine drug screen as well as vaccination, TB testing, CPR certification. If I choose to transition from theRogue Community College Nursing Program to Oregon Health & Science University School of Nursing (aftercompleting the RCC program and passing the NCLEX-RN) I will undergo a separate Criminal Background Checkfor OHSU at the time of transition. I understand my ability to enroll in OHSU courses may be negatively impactedby any criminal history in my background. I understand I would also have to meet OHSU’s credit requirements toearn the BSN.12. I understand that although RCC does not currently mandate COVID-19 vaccination for students; however, thecurrent mandate for the State of Oregon and healthcare workers may require a COVID-19 vaccination to allowme to participate in required clinical practice at selected healthcare facilities.13. I understand admission to the program and enrollment in NRS231, NRS233, NRS115 and NRS115C in springrequires a full-time commitment to the program, and I will be responsible for arranging my work schedule so asnot to conflict with class or clinical requirements.14. I understand that I must pay the 100 application fee to RCC Marketplace.15. For international students only: See Enrollment Services for admissions and registration information.16. I have attached a copy from the OSBN website aspx) ofverification of my unencumbered Oregon LPN license. I understand my LPN license must remain current andunencumbered throughout the advanced placement process.17. I understand that if I have a financial hold at RCC, my application WILL NOT be processed unless the financialhold is removed before 5pm October 15, 2021.18. I understand that reading and following directions is critical to success in any nursing program. Incompleteapplications (e.g. not completing admission to college, lack of application/testing fee, lack of submission of officialtranscripts to Enrollment Services or attached to application, lack of signature, etc.) will result in disqualificationand that disqualified applicants will only receive notice of such after the application deadline has passed.19. I understand to earn selection points for being a military veteran (or active military) I must attach proof ofhonorable discharge or active status in good standing.20. For hospital experience points as a CNA-2 acute care student or employee, PN student or LPN employee, or amedic or corpsman I must attach a completed Hospital Experience form. (Several copies may be submitted ifneeded to show a total of 500 hours.)21 I understand to earn selection points for volunteerism I must attach the required verification forms attached to theapplication.22. I understand to earn selection points for a foreign language that I must provide documentation as mentioned inthe LPN Advanced Placement Selection Points document.Name (Printed)Signature ---------------------------------------The Practical Nursing program adheres to the RCC nondiscrimination statement. Rogue Community College does not discriminate inany programs, activities, or employment practices on the basis of race, color, religion, ethnicity, use of native language, national origin,sex, sexual orientation, gender identity, marital status, veteran status, disability, age, pregnancy, or any other status protected underapplicable federal, state, or local laws. For further policy information and for a full list of regulatory specific contact persons visit thefollowing webpage: www.roguecc.edu/nondiscrimination.5

MRCCROGUE COMMUNITY COLLEGE ,JOCNl1Oregon c.msatum kriNu:sing Educeb:nRogue Community Col.kg,eLPN/RN Advanced Placement Nursing ProgramPoint Criteria NotificationThe following information is to notify the application/selection committee that I am requesting certain localcriteria points and have provided the required information and forms. Please complete and include withapplication and agreement.Applicant Name:Possible Additional Selection Point ItemsRCC ID:Yes or No(check the box)I have previously earned an Associate’s Degree orhigher at a regionally accredited College/University.YESNOI am seeking points for Jackson or JosephineCounty Residency and have an RCC LPN PracticalNursing Certificate.I have repeated BI231 or BI232 or BI233 at leastonce in the past 7 years. (W & AU attempts countas repeats)I am a military veteran and have submitted myDD214 as proof of my honorable discharge fromthe service or am active duty and have attachedproof of status.I am seeking points for Jackson or JosephineCounty Residency and have taken a minimum of12 credits of any courses at RCC at any time in thepast.I am seeking points for foreign language.YESNOYESNOYESNOYESNOYESNOYESNOYESNOI am seeking points for communityservice/volunteerism.I am seeking points for hospital work experience inthe specified capacity.6Additional InformationHighest degree completed,and month/year ofgraduation:Identify what proof you areproviding/attaching or whatwe should look for ontranscripts:Requires attached form to besigned by applicant andcompleted by supervisor,with evidence organization isnon-profit.Requires attached form to becompleted and signed bysupervisor.Completedat (SchoolName)

MRCCROGUE COMMUNITY COLLEGE ,JOCNl1Oregon c.msatum kriNu:sing Educeb:nRogue Community Col.kg,eLPN/RN Advanced Placement Nursing ProgramWork Experience VerificationWORK EXPERIENCEStudent Name:Date: RCC ID:Please PrintDear Employer/Supervisor/Human Resources Manager:The above individual is planning to apply to the RCC Nursing Program by the deadline of October 15, 2021 foravailable LPN advanced placement positions beginning the winter term. The applicant must proveaccumulation of a minimum of 500 hours work experience as a Licensed Practical Nurse (in any setting in aposition that requires the LPN license, is regularly supervised by an RN or licensed independent healthcarepractitioner, and for work at the LPN Scope of Practice that would qualify for license renewal in Oregon).To assist this applicant with the process, please respond to all questions, fill in the requested information,and return it to the application before the application deadline. The applicant may submit documents frommore than one employer in order to provide proof of required hours of work experience.If you have any questions you may email me at lhill@roguecc.edu. Thank you for your help.Sincerely,Laura A. Hill EdD, MSN, RNCDean of InstructionHealth & Public ServiceI verify that this applicant has worked as an LPN at this facility in a position for which an LPN license isrequired, with duties within the scope of practice of an LPN, and in which regular supervision by a registerednurse or licensed independent health care practitioner authorized to make changes in patient plans of careoccurs.Total Number of Hours Worked here as LPN Write “NA” for “Not Applicable” on the “Total hours” line above IF the position does not require LPN licensureor IF the LPN is not regularly supervised by an RN or a licensed independent health care practitioner (e.g. aNurse Practitioner or M.D.).Signature of Supervisor or HR ManagerPrinted Name and TitleFacilityPhone Number7

MRCC Community College,ROGUE COMMUNITY COLLEGEOregon Oomcmim b-t hr.iing Educati:nLPN/RN Advanced Placement Nursing ProgramCOMMUNITY SERVICE VOLUNTEER VERIFICATION FORM 2021Student Name:Date: RCC ID:Please PrintLPN applicants to the Rogue Community College Nursing Program through advanced placement may receiveup to 5 points for volunteering for a non-profit organization where the individual was supervised (directly orindirectly) and provided a service which benefits a community. Travel time cannot be counted as volunteertime.Note to applicant: Be sure the spaces indicated on this form are entirely completed. Provide this form to yoursupervisor/organization where the volunteer hours were performed. Volunteer hours must be verified using thisform and include a description by your supervisor (who cannot be a relative) of the activity and how itserves the community. You may duplicate this form as needed. Incomplete forms (e.g., lack of supervisor’sdescription of the activity and how it served community) cannot be given consideration in the point assignmentprocess. Have your supervisor/organization return this form to you BEFORE October 15, 2021.Dear Human Resources/Supervisor,I am in the process of applying to the Rogue Community College LPN Advanced Placement Program and amseeking possible points for volunteerism. The process requires verification of volunteer hours for a non-profitorganization and a supervisor’s description of how the volunteer service benefits the community. Volunteerhours must be unpaid and completed between October 2016 and October 2021.I, (print program applicant’s name) authorize the college to contact theindividual(s) listed on this form to verify the information provided.Applicant’s Signature: Date:The portion below is to be completed by Supervisor or Human ResourcesVerification of unpaid volunteer hours serving the community in a charity or non-profit organization:A.C.Dates of Service: Total Hours:mm/dd/yy – mm/dd/yySupervised by:Print Name, TitleOrganization: Non-Profit (check): yes no; EIN:D.Supervisor contact number:E.Supervisor email address (must be organizational email):F.Supervisor’s description of the volunteer activity and how it serves the community, including numberof people directly affected and how you supervise the applicant (attach additional pages as necessary)Note this to verify volunteerism and not a reference letter for applicant:B.Supervisor signature: Date:8

ROGUE COMMUNITY COLLEGELPN/RN Advanced Placement Nursing ProgramCNA-2, LPN, MEDIC/CORPSMAN HOSPITAL EXPERIENCEStudent Name:RCCID:Date:Dear Instructor/Supervisor/Commander/Human Resources Manager:The above individual is planning to apply as an LPN for advanced placement in the RCC Nursing Program by October 15,2021. To earn two points in the selection process, the applicant must prove accumulation of a minimum of 500 hours ofpatient care as a student or employee or medic or corpsman in a hospital in any of the above roles in the past five years.To assist this applicant with the process, please fill in the requested information and return it to the applicant. Theapplicant may submit documents from more than one person in order to provide proof of hours of hospital experience.The applicant must include this document with their application if they are seeking these two points. The deadline isOctober 15, 2021, at 5 PM.Sincerely,Laura Hill, EdD, MSN, RNCInterim Nursing DirectorPlease verify the number of patient care hours (work in any other capacity does NOT count) this applicant has had as aCNA-2 student or employee, PN student or LPN employee, Medic or Corpsman at your hospital facility:Total Number of Hours, in past 5 years, of patient care in hospital as [insert role: ] [insert role: ] [insert role: ] [insert role: ] Signature of Instructor, Supervisor, HR Manager or Commanding OfficerPrinted Name and TitleContact Phone:Contact email:Click to Submit Application Agreement9

_ 2. I understand that by making application to the Rogue Community College Nursing Program LPN Advanced Placement I am also applying for co-admission to OHSU and authorizing the release of my application and academic information to OHSU as required to facilitate my program of study or for statistical or evaluative purposes. _ 3.