RN to BSN Nursing Program Application

CURRENT STUDENTS | FUTURE STUDENTS | FACULTY/STAFF | A-Z

Name
Current Mailing Address:
E-mail Address:
Phone Numbers
Home:
Work:
Cell:
Best number to contact you?	Home Work Cell

Do you have a current R.N. license?	Yes No
Which state?
What year did you receive your RN license?
License #

Have you been admitted to WNMU?	Yes No
What is your first anticipated semester of enrollment?
Employment status:
Number of hours worked per week:
Gender:	Male Female
Marital Status:	Married Single Divorced
Number of dependents:
What is your U.S. state of residency?
Please select your age range:

Education Experience:
List all higher education institutions you have attended, your program of study and/or any degrees you have received.

Have your student records ever been under a different name(s)?	Yes No
Other name(s):
You are almost done...
Please rate each of the following statements:
I am comfortable using a computer.
I am comfortable using e-mail.
I have used chat and discussion boards on the internet.
I anticipate being an active participant in an online course.
I am self-disciplined.
I find writing easy.
How did you find out about us?
Ethnic Origin:
What is your first language?
Are you disabled?	Yes No
If you answered yes on the last question, what disability do you have?
Military Service
If you are a military veteran, do you anticipate using your G.I. Bill benefits?
Will you need financial aid to complete the BSN program?	Yes No
Do you plan to participate in a tuition reimbursement program through your employer?	Yes No
Have you ever taken an online course?	Yes No
Do you have a reliable computer?	Yes No
Do you have internet access?	Yes No
What type of connection do you have?

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