Refer to the LVN_RN Nursing Program Application Checklist to make sure you have completed the application process thoroughly and accurately. Applicants who submit incomplete applications or who are missing any required documents will automatically be ineligible. Your application must be completed within 2 hours. You will not be able to save and return to make any changes or submit at a later time. Only one application submission per application cycle is allowed. Student First Name Student Last Name Student Middle Name Previous Maiden Name(s): (if any) Street Address City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Phone My Canyons Email My Canyons Email Verify My Canyons Email Do you have a Social Security #? Yes No COC STUDENT ID # Have you ever attended another Nursing Program or any program which included placement in a clinical facility? Yes No If yes, type of program, name of school, dates of attendance? Did you complete the program? Yes No If no, are you eligible to return to this program? Yes No Has your LVN license ever been suspended or revoked in any state? Yes No Have you ever been placed on probation by the Vocational Nursing/Psychiatric Technician (BVN/PT)? Yes No If yes, please explain Are you a U.S. citizen? Yes No If no, are you in the U.S. as a Permanent Resident? Yes No If yes, Document # If no, are you in the U.S. on a Visa? Yes No If yes, type of Visa Visa# Are you lawfully eligible to work in the U.S.? Yes No Check all that apply No college degree posted on transcript Must attach copy of high school transcript, OR copy of diploma, OR copy of GED certificate. If from foreign country, must provide translation. Previously applied to COC RN Program? Yes No Month/Year: Completed a COC Nursing Remediation Plan? (Note: Remediation Plans are offered to past applicants who did not meet minimum requirements in either the “Cut Score” or “TEAS” section of the nursing application process) Yes No Month/Year: Previously completed the ATI TEAS - Version 7 (effective June 2022 - first attempt only) Yes No If yes, where Date: (mo/yr) List All Colleges Attended (include College of the Canyons, universities/military, USA/foreign; failure to list all colleges attended will result in ineligibility.) College Information Re-order Name of College Degree Earned Weight Operations Name of College Degree Earned - Select -No DegreeAssociateBaccalaureateMaster'sDoctoral Item weight Add more items more items To list all college attended, use + and – to add or delete colleges. One college per line. Multicriteria Screening Check all that apply: Education/Experience BS/BA Experience Information Employment LVN employment for at least one year in the last three years. NOTE - one year work experience can be waived if student has completed an LVN progam within the last year (10/1/24-9/30/25) and has a valid LVN license. (must attach verification of LVN employment letter from your employer, as proof of at least 1 year LVN experience within the last 3 years, on official letterhead, signed by employer. Letter must include your name, job title, brief job description, and dates of employment. (.pdf files only) Life Experience Disabilities (The same meaning as used in Section 2626 of the Unemployment Insurance Code) Low Family Income (Measured in terms of a student's eligibility for, or receipt of, financial aid under a program that may include, but is not necessarily limited to, a fee waiver from the Board of Governors, The Cal Grant Program, the federal Pell Grant program or CalWORKS) First generation of family to attend college Need to work (The student is working at least part time while completing academic work that is a prerequisite for admission to the nursing program) Disadvantaged social or emotional environment (Includes, but is not limited to, the status of a student who has participated in EOPS) Difficult personal and family situations or circumstances Refugee or veteran status Language Proficiency Proficiency or advanced level coursework in languages other than English (list below) Language Proficiency Information My signature is mandated and indicates that I have completed all sections truthfully. I understand that should I be admitted to the COC Nursing Program, any falsification, misrepresentation, or omissions of facts are sufficient reason for dismissal upon discovery at any time during the nursing program. I authorize the release of College of the Canyons transcripts to the COC Nursing Department when I apply and each semester that I am a part of the program. I will provide further documentation if requested. Student Signature Affirmative Action Information This information is confidential and is gathered for statistical purposes only. The information provided below, or the failure to provide the information below, will in no way affect your ability to enter the nursing program. Gender Male Female Other Ethnicity White (All persons having origins in Europe, North Africa or the Middle East and not of Hispanic origin) Hispanic (All persons of Chicano, Mexican, Puerto Rican, Cuban, Central/South American, or other Spanish culture origin regardless of race) American Indian (All persons having origins in the original peoples of North America and who maintain cultural identification by virtue of tribal association or community recognition) Asian/Pacific Islander (All persons having origins in the Far East, Southeast Asia, the Indian Subcontinent, or Pacific Islands, including the Philippine Islands) Black (All persons having origins in any of the black racial groups of Africa and not Hispanic in origin) Other (please describe) Ethnicity Other EducationHighest level of education obtained to date Associate Degree Baccalaureate Degree Master's Degree Doctoral Degree No Degree Age Language spoken in the Home Persons with Disabilities It is your responsibility to notify the Disabled Students Programs and Services office at the College with verified documentation from a health or learning specialist in order to receive reasonable accommodation. Non Discrimination Policy The School of Health Professions does not discriminate on the basis of ethnic group identity, religion, sex, age, color, national origin, marital status, sexual orientation, veteran's status, mental disability or physical disability including persons with AIDS/ARC/HIV in any of its policies, procedures, or practices. This non-discrimination statement covers admission and access to, and treatment and employment in the programs, services and activities. File Uploads Please attach the applicable documents needed to complete your LVN_RN Nursing Application as .pdf FILES ONLY. If you checked the box indicating no college degree posted, you must attach copy of high school transcript, OR copy of diploma, OR copy of GED certificate. If from foreign country, you must provide translation from an official agency. Must attach copy of current LVN license (from BREEZE verification) Must attach verification of employment letter with proof of at least 1 year employment within the last 3 years as LVN on official employer letterhead. Letter must include your name, job title (LVN) and dates of employment. Please note - If you have completed LVN school within the last year (10/1/24-9/30/25) you do not need to include the work experience as LVN to be considered for selection. File Uploads Maximum 10 files.15 MB limit.Allowed types: pdf. Leave this field blank