Instructions for Application to the Baccalaureate Nursing Major at MSUM • All applicants must be admitted to MSUM before submitting the nursing application and have a Dragon ID. Students not fully admitted to MSUM will not be considered for admission to the baccalaureate nursing program. Non-admitted students may request application forms from the Office of Admissions at www.mnstate.edu/admissions. • Two MSUM reference forms are required. They must be sealed and signed across the sealed envelope flap and included with this application. • All application materials must be received by the nursing department (or be postmarked) by February 15th. Unofficial transcripts from all schools attended, including high school must be submitted with the nursing application. It is the applicant’s responsibility to verify that the nursing office has received all application materials by the deadline. • The following checklist may be helpful in completing your application. ❑ Acceptance to Minnesota State University Moorhead ❑ Application to the Nursing Program, including essay ❑ Two MSUM reference forms ❑ An interview may be requested. If so, you will be notified. • This application can be completed online, printed, signed and mailed. Date Application Received __________________ Admission Criteria • Admission to Minnesota State University Moorhead • Minimum cumulative high school and/or college GPA of 3.25 • High school or introductory college-level biology and chemistry • Two MSUM reference forms from teachers, counselors or employers • Prior education and life experience may be considered • Preferred ACT score of 24 or preferred SAT score of 1100 • Possible personal interview Baccalaureate Nursing Program Application MSU Moorhead Department of Nursing 1104 7th Avenue South Moorhead, MN 56563 218.477.2693 The application deadline is February 15, 2007 Department Use Only Application Name __________________________________________________________________________________________________________ Last First Middle Former name, if applicable Current Mailing Address ___________________________________________________________________________________________ Street City State Zip Permanent Address _______________________________________________________________________________________________ Street City State Zip Phone Number ___________________________________________________________________________________________________ Home Cell Work Current e-mail address _____________________________________________________________________________________________ MSUM Student ID number (REQUIRED): _______________________________________________________________________________ Social Security Number _________________________________________ Please print or type online Name of Institutions Degree/diploma Year Education: Begin with high school and list ALL colleges attended including schools of nursing: (Use additional sheet if needed.) Are you currently enrolled in college? ❑ Yes ❑ No Employment (begin with present position and list previous employment in reverse chronological order). Continue on back if needed. 1. Present Position 2. 3. 4. Agency Name Type of position Dates of employment Type of agency Other experience not included in work history that you believe would be relevant to consideration of your application (e.g. community projects, student exchange programs, volunteer work, awards, etc.). (OPTIONAL INFORMATION): The information requested below is voluntary and will be used for summary reports required by federal and state laws and regulations and to support institutional affirmative action efforts. It will not be used as a basis for admission or in a discriminatory manner. You will not be subjected to adverse treatment if you do not provide any of the requested information. Gender: ❑ Male ❑ Female Birthdate: _________________________ Race/Ethnicity: ❑ Black ❑ American Indian or Alaskan Native ❑ Asian or Pacific Islander ❑ White ❑ Hispanic ❑ Multi-Ethnic background (please list) If you have attended or been admitted to another program of nursing at a hospital, college or university please indicate the name and address of the program and your reason for leaving. _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ In a typed, double spaced paper not longer than 500 words, address the following points: 1. What qualities and/or life experiences have led you to pursue nursing as your chosen profession? 2. Briefly describe your professional goals upon completion of your baccalaureate degree in nursing. 3. Discuss one or more specific health care issues which interest you and any experience you may have related to these areas (e.g., domestic abuse, smoking cessation, etc.). 4. Describe your strengths and weaknesses. 5. Discuss why you believe you would be successful in the BSN Program at MSUM. The review and grading of the essay will include, but not be limited to the following: • Clear expression of thought • Grammar/sentence structure/spelling/overall appearance • If the essay questions/topics were completely addressed All applicants are requested to supply two confidential MSUM reference forms (relatives and family friends are not appropriate). Reference forms should be from an instructor, employer or a member of a helping profession-clergy, nurse, counselor, former college teacher. Include reference forms in a sealed signed envelope with your application. Reference forms can be found on the nursing department web page or in the nursing office. Undergraduate Nursing Student Functional Abilities Release Department of Nursing Undergraduate students must be able to perform the functional abilities in each of the following categories: gross motor skills, fine motor skills, physical endurance, physical strength, mobility, hearing, visual, tactile, smell, reading, arithmetic competence, emotional stability, analytical thinking, critical thinking skills, interpersonal skills, and communication skills (National Council of State Boards of Nursing, 1999). However, it is recognized that degrees of ability vary widely among individuals. Individuals are expected to discuss questions about abilities with the Director of Nursing in the Department of Nursing. The policy, Functional Ability Requirements for Undergraduate Nursing Students & Common Activities/Tasks Required in the Nursing Progression, can be accessed on the Department of Nursing Web site at www.mnstate.edu/nursing or is available on request. “I have read the Functional Ability Requirements for Undergraduate Nursing Students and Common Activities/Tasks Required in the Nursing Profession. I know with whom to discuss my disability and possible accommodations, if needed.” Signature of Applicant Date National Council of State Boards of Nursing. (1999). Guidelines for using results of functional abilities studies and other resources. Chicago, IL.: Author. References Minnesota State University Moorhead is an equal opportunity educator & employer and is a member of the Minnesota State Colleges & Universities System. This information will be made available in alternate format, such as Braille, large print or audio cassette tape, upon request by contacting Disability Services at 218.477.5859 (voice) or 1.800.627.3529 (MRS/TTY). Department of Nursing 1104 7th Avenue South Moorhead, MN 56563 218.477.2693 For general questions call the nursing department at 218.477.2693 Send completed nursing application form to: I certify that all information and documents are complete and accurate. Misrepresentation of application information is sufficient grounds for suspension or canceling admission. Signature _________________________________________________________________ Date ___________________________ Departmental Requirements After admission to the nursing major, additional requirements will include the following: • Criminal background check (annually): If the review disqualifies you from providing care, your circumstances will be individually evaluated. • Current evidence of annual Tuberculin test clearance (Mantoux). • CPR Certification at the AHA Healthcare Provider level or American Red Cross Professional Level. I certify that I have read and understand these departmental requirements. Applicant’s Signature _____________________________________________________ Date _______________________