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Practical Nursing (High School Student)
For high school Practical Nursing students only.
Name (First, Middle, and Last) *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Email *
Your answer
Base School *
Grade *
Date of Birth *
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DD
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YYYY
Address (Street, City, State, Zip Code) *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
GPA *
How many days of school did you miss last year? *
Reason for absences:
Your answer
Explain in 2-3 sentences why you want to take this course. *
Your answer
Student ID Number (Lunch Number) *
Your answer
Is this BSTC course your 1st, 2nd, or 3rd choice? *
How did you hear about this course? *
Are you a U.S. Citizen? *
Are you a Bedford County/City Resident? *
Person to be notified in case of emergency: *
Your answer
Relationship of Emergency Contact *
Your answer
Address of Emergency Contact *
Your answer
Phone number of Emergency Contact *
Your answer
Work and Work Address of Emergency Contact *
Your answer
Have you previously applied for admission to this school? *
Accepted:
Attended:
If "Yes", please list dates
Your answer
Academic year applying for: *
Your answer
Work History: List all work experience, both full and part-time, beginning with the most recent. (Date/Company or Firm/Address/Job Title/Phone Number)
Your answer
Volunteer and Community Service: *
If "Yes", please explain:
Your answer
Have you ever been convicted of a felony and/or Misdemeanor since the age of 18? *
If "Yes", please give details (offenses/dates/sentences/etc)
Your answer
Being successful takes hard work. Tell about a time when you had to work very hard to reach your goals. Be specific about what you achieved. *
Your answer
Give an example of a time when you put forth a special effort to understand another person's situation or dilemma. How did you show sympathy or compassion to that person? *
Your answer
Tell about your computer skills, specifically, Word, Excel, Access, and Powerpoint. How often and in what capacity have you used these programs? *
Your answer
Give an example of a time that you feel that you "went above and beyond the call of duty" to help out your team/friends/coworkers? *
Your answer
You will be required to give the names and addresses of three persons, not relatives or friends, who know you and can give information about you (for example, you may include a recent teacher, counselor, or employer). Please print out three applicant reference forms and have the appropriate person complete and return the form to the School of Nursing. REFERENCE FORMS CAN BE FOUND NEXT TO THE RESPECTIVE COURSE APPLICATION. Please acknowledge that you have read and understand this by choosing "I understand" below. *
1st Reference Name *
Your answer
1st Reference Position or Title *
Your answer
1st Reference Address *
Your answer
2nd Reference Name *
Your answer
2nd Reference Position or Title *
Your answer
2nd Reference Address *
Your answer
3rd Reference Name *
Your answer
3rd Reference Position or Title *
Your answer
3rd Reference Address *
Your answer
I hereby formally make application for admission to the Bedford County School of Practical Nursing and assert that the information given in this application is true and accurate to the best of my knowledge. I understand that any misstatement of facts will cause forfeiture of all rights to admission to/ or dismissal from the Bedford County School of Practical Nursing. To agree to the terms above, please type your FULL NAME below. *
Your answer
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