St. Luke's -

Personal Information

Legal Name

First Name

Middle Name

Last Name

Former last name(s)/maiden name, if any, under which transcripts, test scores or other information may be submitted:

Date Of Birth
(mm/dd/yyyy)

Social Security Number
(123-12-1234)

Home Address Number

Street

R. D. / Box #

City

State

Zip

County

Primary Phone Number (123-123-1234)

Alternate Phone Number (123-123-1234)

Email Address

Demographic Information

THESE ITEMS ARE OPTIONAL – This information is requested for statistical use only in accordance with applicable federal regulations.

Gender Female
Male

How would you describe your predominant ethnic background? American Indian or Alaska Native
Asian
Black or African American
Hispanics of any race
Native Hawaiian / Other Pacific Islander
White
Two or more races
Race and ethnicity unknown

Emergency Contact Information

Emergency Contact Name

Relationship To Emergency Contact

Emergency Contact Address

Emergency Contact City

Emergency Contact Phone Number (123-123-1234)

Educational and Character Information

Please provide your desired date of entrance to St. Lukes's School of Nursing: (mm/yyyy)

Have you previously applied to or attended St. Luke's School of Nursing?

Do you work or have you ever worked at St. Luke's University Health Network?

Are you a current St. Luke's University Health Network employee?

Are you a U.S. citizen?

Were you educated outside the United States? Yes
No

Is your first language English? Yes
No

Please note: Test of English as a Foreign Language (TOEFL) may be required for applicants who are non-native speakers of English to measure their ability to use and understand English as it is spoken, written and heard. Please contact the Admissions Office at 484-526-3443 for more information.

Educational and Character Information Continued

All applicants must hold a high school diploma or high school equivalency certificate (GED). Please indicate which applies to you: High School Diploma
GED

Starting with your most recent school, please fill out the relevant information for any educational institution you have attended. Please enter the name of the school, entrance and exit dates, and the degree you received (if applicable).

List any and all high schools and post-secondary schools attended, regardless of whether you graduated. Please note: Attendance at all institutions must be reported at the time of application. An applicant's failure to disclose that he or she has taken a course(s) from another institution shall result in the denial or revocation of admission and dismissal from the School.

High School

High School Name

Diploma/Degree Received

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

High School Name (if needed)

Diploma/Degree Received

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

GED

GED Completion Date (mm/dd/yyyy)

College/Technical School

School Name 1

Diploma/Degree Received

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

School Name 2 (If needed)

Diploma/Degree Received

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

School Name 3 (If needed)

Diploma/Degree Received

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

School Name 4 (If needed)

Diploma/Degree Received

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

School Name 5 (If needed)

Diploma/Degree Received

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

School Name 6 (If needed)

Diploma/Degree Received

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

School Name 7 (If needed)

Diploma/Degree Received

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

School Name 8 (If needed)

Diploma/Degree Received

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

Education and Character Information Continued

Have you ever been suspended, dismissed or withdrawn from any school? No
Yes

If yes, please explain, including dates. (Please limit response to 2000 characters.)

Have you ever been suspended, dismissed or asked to resign from any job or work experience, including internship, observation or volunteer experience? No
Yes

If yes, please explain, including dates. (Please limit response to 2000 characters.)

Please list and explain all convictions, guilty pleas and nolo contendere pleas (except for minor traffic violations not related to the use of drugs or alcohol). This includes but is not limited to misdemeanors, felonies, driving under the influence (DUI) and driving while intoxicated (DWI). Crimes must be reported even if your sentence is/was suspended such as a result of entry into the Accelerated Rehabilitative Disposition program or ARD. Dates and location(s) must be included in your explanation. Please specify Pennsylvania or any other state, territory, possession or country, whether in the U.S. or abroad. If question is not applicable, please indicate "N/A"

Have you ever been enrolled in another nursing program? If Yes, provide the nursing program. If question is not applicable, please indicate "N/A"

Compliance Information

NOTICE OF NON-DISCRIMINATION POLICY

The St. Luke’s School of Nursing is in compliance with applicable federal, state and local laws, regulations and ordinances governing equal opportunity and non-discrimination, including without limitation, Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, as amended, Section 504 of the Rehabilitation Act of 1973, as amended, the Americans with Disabilities Act of 1990, and the Age Discrimination Act of 1975. The School of Nursing provides equal educational opportunity to qualified applicants and students and does not discriminate on the basis of age, sex, ancestry, race, color, national origin, religion or disability in recruitment and admission, educational programs and policies, housing, scholarships and loans programs, or nonacademic services such as recreation, counseling, or social activities. The Director is responsible for the implementation and coordination of equal opportunity in the School of Nursing.

APPLICANT ACKNOWLEDGEMENT

As an applicant to St. Luke's School of Nursing ("St. Luke's"), I understand that all of the information I have provided on my application for admission and otherwise in connection with the application process will be relied upon by St. Luke's to determine my qualifications for admission. I hereby acknowledge that all of the information I have provided in response to inquires on this application for admission and all information I have provided otherwise in connection with the application process are true, correct and complete. I understand that any false, misleading, or incomplete answer, statement or implication made by me in connection with this application or the application process, or any failure to disclose any relevant information, shall result in the denial and/or revocation of admission to St. Luke's, including dismissal from St. Luke's, if matriculated, and may also lead to future denial and/or revocation of licensure in Pennsylvania as a Registered Nurse.

I hereby grant St. Luke's permission to investigate my personal, criminal, educational and employment background and history and to contact persons, organizations, institutions or government agencies who may have knowledge of me. In consideration for St. Luke's reviewing my application for admission, and intending to be legally bound, I hereby release St. Luke's School of Nursing, its parent, subsidiaries, affiliates, trustees, officers, employees and agents (collectively hereinafter referred to as "St. Luke's"), from any and all claims or liability, known or unknown, arising from St. Luke's investigating my background and all persons, organizations, institutions or government agencies supplying such information.

Finally, it is my understanding that I shall not be considered for admission to St. Luke's until I have submitted all credentials and otherwise satisfied all requirements for a timely and complete application for admission. I further understand that an applicant who satisfies all application requirements is not guaranteed admission into St. Luke's diploma program. I agree to inform St. Luke's of any changes in the information I have provided on this application or otherwise in connection with the application process. If St. Luke's offers me admission, and I decide to matriculate, I agree to comply with any and all of St. Luke's policies, rules and regulations, as amended from time to time.

I have read and agree to these terms.

Credit Card Information

The application fee for the St. Luke's School of Nursing application is $35.

Payment Information

Payment Method:

Billing Address

Same As Applicant

First Name

M.I.

Last Name

Address

City

State (NY)

Zip Code (12345)

Credit Card Information

The application fee for the St. Luke's School of Nursing application is $35.

Credit Card

Card Number (1234-1234-1234-1234)

CVV2

Exp. Date

Page 1

Personal Information

Legal Name

Demographic Information

Emergency Contact Information

Educational and Character Information

Page 2

Educational and Character Information Continued

High School

GED

College/Technical School

Page 3

Education and Character Information Continued

Page 4

Compliance Information

NOTICE OF NON-DISCRIMINATION POLICY

APPLICANT ACKNOWLEDGEMENT

Page 5

Credit Card Information

The application fee for the St. Luke's School of Nursing application is $35.

Payment Information

Billing Address

Credit Card Information

The application fee for the St. Luke's School of Nursing application is $35.