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1Miles Community CollegeASSOCIATE OF SCIENCE NURSINGApplication FormApplicant Name:Applicants to the MCC Nursing Program must submit by June 1st: The general MCC Application with processing fee & signature page to Student ServicesOfficial high school/ college transcripts to the Registrar’s officeComplete Nursing Program application including: Kaplan results (if tested someplace otherthan MCC), proof of insurance, copy of CPR certification, proof of immunizations, signedpolicy acknowledgment page, and any other pertinent documents as needed.For more information contact:Miles Community College Nursing Dept.2715 Dickinson St.Miles City, MT 59301(406) 874-6189helmtsk@milescc.eduMCC Nursing Application2021

2APPLICANTPlease mark if request for p** Notification of acceptance/denial will be sent to this address**County:PhoneNumber: Email:Social Security Number: Date of Birth:CLINICAL SITE REQUESTPlease indicate your preference of clinical site by ranking the four designated clinical sites 1-5, onebeing most desirable. Placement is determined by number of applicants and/or yearly agreement withthe individual sites and is not guaranteed.Miles CitySidneyGlendiveBillingsWolf PointAdditional comments:MCC Nursing Application2021

3EDUCATIONHigh School/EquivalencyCity/StateDate of GraduationPlease list all colleges & universities attended, including Miles Community College:Name & location of schoolMajorDatesAttendedCredit HoursLICENSURE (if N.A.L.P.N. *Check for transcriptconsiderationsEMT/ParamedicOther fieldexperience:HEALTHCARE WORK HISTORY (if applicable)Position HeldMCC Nursing s)Obtained

4MILITARY EXPERIENCE (if applicable)*check for transcript nHEALTH INSURANCECompany PhoneSubscriber’s NamePolicy Number** If you do not have health insurance, obtain a Health Insurance Waiver form from the NursingAdministrative Assistant or print one from the MCC Nursing website singInsuranceWaiver.pdf (this document must benotarizedEMERGENCY CONTACT INFORMATIONName of emergency contactRelationship to applicantPhone Numbers cell workAlternate contact:Relationship to applicant:Phone Numbers: cell workMCC Nursing Application2021

5IMMUNIZATIONSApplicants must attach proof of the following required immunizations OR proof of positive labtiter: Measles (Rubeola), Mumps and Rubella (MMR)Varicella (2 doses)Tetanus, Diptheria, Pertussis (Tdap) series within the last 7 yearsHepatitis B SeriesTB Test: Two-Step within three months of start date OR IGRA Blood Test (Quantiferonor T-Spot) OR negative chest X-ray. Results MUST be completed one week prior to thestart of school or applicant will be dismissed.The following are recommended immunizations for nursing students: Hepatitis A Meningococcal Meningitis InfluenzaAcceptable proof of immunizations are copies of immunization records from the applicant’smedical provider or a copy from the state immunization registry (Public Health). For questionsor assistance with obtaining immunization records, please try the following CopyofImmunizationRecordMCC Nursing Application2021

6BACKGROUND CHECKApplicants are required to complete a criminal background check as part of conditional admission to thenursing program. These background checks MUST be completed through MCC’s contracted company,Verified Credentials. The cost of the background check is 75 (subject to change). Applicants need touse the login provided as well as the provided code. The appropriate program staff will be able toaccess the results of your background check through the VC site. Verified Credentials requires MilesCommunity College to have a signed “Disclosure & Authorization” on file for each applicant. Thisdocument has been provided within this packet, please sign, date and return with the application.NOTE: This is a TWO step process! Once the background check has been initiated theapplicant will receive an email from Verified Credentials asking for further authorization tofinalize the background check. The background check is NOT complete until the applicant hasacknowledged the email!Login- - RTPPB-77723 (Background Check-Nursing-New Students)Additional background questionsPlease answer the following questions by circling your response. If you answer “yes” to any of thequestions, please provide a complete description of dates and circumstances on a separate paper.You must send applicable supporting court documents. Additional drug screen checks may berequired for licensure and/or clinical placement. Felony convictions may result in denial ofacceptance to the program and/or eligibility of Registered Nurse (RN) licensure. Have you ever been convicted, pled guilty or no contest, or received a suspended impositionof sentence for any criminal offense excluding minor traffic violations?Yes No Have you ever been convicted, pled guilty or no contest, or received a suspended impositionof sentence for any felony?Yes No Are there any pending criminal proceedings against you?Yes No Have you been treated for abuse or misuse of alcohol or a chemical substance? Yes No Have you experienced a physical, emotional, or mental condition that has endangered thehealth or safety of yourself or others?Yes No Have you ever had a professional license, certification, or registration in Montana or anyother states denied, cancelled, limited, suspended or revoked?Yes No Have you ever appeared, or been requested to appear, before any licensure board concerningany violation by you of any law, rule or regulation of any state, district, territory, or province ofthe United States or Canada?Yes NoMy answers to the above questions are true, accurate, and complete to the best of my knowledge. Iunderstand that any falsification will be considered grounds from dismissal from the MCC NursingProgram should I be accepted.Applicant’s Signature DateMCC Nursing Application2021

7BACKGROUND CHECK DISCLOSURE & AUTHORIZATIONDisclosure for Release of Information: Verified CredentialsWith your authorization, Miles Community College Nursing will obtain abackground report about you for purposes of your participation in an educationalprogram with it, which may include participation in clinical or other similarprograms(s). The authorization you give will allow the nursing department toobtain this report, as well as additional reports, before and during yourattendance there. These reports may include information about your character,general reputation, personal characteristics and/or mode of living, whichever maybe applicable. Contained in these reports may be criminal record informationabout you, information about your prior employment, education, licenses andcertifications or other background information about you.Authorization to Obtain Background ReportsI certify that I have received, read and understand the separate documents (within the VerifiedCredentials site) entitled Disclosure Regarding Background Reports, Disclosure RegardingInvestigative Background Reports (if applicable) and A Summary of Your Rights Under the FairCredit Reporting Act. I authorize (Miles Community College) (the “Organization”) to obtainbackground reports regarding me. To this end, I authorize any law enforcement agency,administrator, state or federal agency, institution, school or university (public or private),information service bureau, employer, insurance company and any other person or entity tofurnish any background information about me. I agree that a facsimile, electronic orphotographic copy of this authorization shall be as valid as its original.SignatureMCC Nursing Application2021Date

8INTERVIEWEligible applicants will be contacted in June to set up an appointment for an on campusinterview. Interviews will be conducted by the Director of Nursing, Nursing & Allied HealthAdvisor, Nursing Faculty and/or other MCC faculty and staff, prior to final selection of theincoming cohort.ACKNOWLEDGMENT OF PROGRAM ADMISSIONREQUIREMENTS & RECOMMENDATIONSThe objective of Miles Community College’s Associate of Science in Nursing Program is toprepare individuals to work as an RN. The program’s governing bodies, AccreditationCommission for Education in Nursing, Inc. (ACEN) and the Montana State Board of Nursing,require that students seeking admission to the program are subjected to requirements andreview procedures above and beyond those associated with general admission to the College.Please read & initial your understanding/acceptance of the following and include copies of anynecessary documentation.I have signed and included the authorization page for Verified Credentials (page 7). Ihave initiated the process to have my background check completed. It is my responsibility toreport any felonies or treatment for substance abuse to the State Board of Nursing to ascertaineligibility issues for licensure.Per MCC Nursing Handbook, 5.5, I have attached a copy of my current certificationof completion of Basic Life Support for Healthcare Providers by the American Heart Assoc. Ifurther understand that I must maintain certification for the duration of the program.In accordance with MCC Nursing Handbook, 5.8, I understand that to progresssuccessfully through the program, pass return skills demonstrations and to function as a nurseafter graduation I possess the following: adequate visual acuity with or without correctivelenses, adequate hearing ability with or without auditory aids, adequate physical ability ofupper & lower extremities, and sufficient speaking, reading and writing ability of the Englishlanguage to effectively communicate.As described in 5.9 of the MCC Nursing Handbook, if I have a documenteddisability, that may impact my progress in nursing courses, it is my responsibility to report thedisability to the MCC Disabilities Coordinator for necessary accommodations.If applicable, I have included an explanation on a separate sheet of ANY knownallergies to food, drugs, environment, latex or any other substance that would affect my abilityto care for patients.I understand that it is my responsibility to be informed of & comply with the MilesCommunity College policies regarding drug & alcohol offenses.MCC Nursing Application2021

9I will maintain a high standard of professional behavior and respect for my costudents, patients, faculty and staff.As dictated by the Montana State Board of Regents, I am aware that the prerequisite science courses may not be older than five years for application purposes.I have reviewed the Miles Community College Nursing Handbook, most currentversion, on the Nursing page of the MCC Nursing/NursingHandbook2020-2021.pdfIf I have any questions regarding the application process, selective GPA or thepoints process for selection, I may find the answers to my questions on the Application FlowChart on the web ng/ApplicationProcess/I understand that if I am selected for the program I will be expected to complete adrug test. (More information will be provided in the acceptance letters)I agree that I will complete the two-step TB screening and provide those results to theNursing Office no later than one week prior to the start of class or risk dismissal from theprogram.Upon request, I will coordinate with the Nursing Office to schedule an on-campusinterview as part of the application process.MCC Nursing Application2021