5800 Uvalde RoadBldg. 17, Office 2114Houston, Texas 77049281-998-6150 Ext: [email protected]:G00Application for Vocational Nursing Program-North Campus: This application and this checklist must be filled outcompletely and submitted to the Vocational Nursing Department during the application period for the semesteryou want to attend. You must submit to the Vocational Nursing Office North Campus (N-17.2114) all items listedbelow IN A SEALED ENVELOPE for review by mail.Check the website for dates and times of application submission.Students applying for admission to the Vocational Nursing program must complete the following steps: to San Jacinto College at the following website ( official copies of all non-San Jacinto College transcripts to the Office of Enrollment Services.Submit Vocational Nursing application to the nursing office at North campus (N-17.2114).Submit official sealed transcripts of all schools attended to the nursing office along with VN Programapplication.Submit HESI A2 Scores to complete your application. You are allowed only two (2) HESI test submissionswithin the past 2 yearsSubmit copy of Healthcare Insurance Card front/back.Submit BON Statement Form. (included in this packet)Submit Skill Level Verification form from Counseling showing a 7 in Reading and Writing, and 8 in math.Students submitting international transcripts must include the SPANTRAN (or equivalent) evaluation.INCOMPLETE APPLICATION SUBMISSION PACKETS WILL NOT BE REVIEWED.Once accepted into the Program applicant will be required to pass a physical exam and Submitdocumentation of required immunizations and CPR Card.All acceptances are conditional of meeting all requirements and submitting all required documentation.Please list all sealed transcripts you are submitting with this application:Revised 2/9/2021

5800 Uvalde RoadBldg. 17, Office 2114Houston, Texas 77049281-998-6150 Ext: [email protected]:G00Applications will be accepted on the dates specified. This application packet must be typed andcomplete upon submission:Please initial all boxes as each item is accounted for:Initial1. Show proof of admission into San Jacinto College. Provide the letter they sent you in the mail or byemail or provide a transcript from San Jacinto College as proof of admission.2. Submit official transcripts to Enrollment Services for Evaluation. official transcripts to the Vocational Nursing Office. We DO NOT accept online print outs andthe department needs its own copy regardless of transcripts submitted to Enrollment Services.Transcripts must be within 60 days of the application date.*If submitting international transcripts, SPANTRAN (or equivalent) evaluation must also besubmitted.**Failure to submit all transcripts will result in an incomplete application and will not be reviewed.**Submit proof of 2.25 or Higher GPA – Cumulative GPA from all previous colleges attended. Validatedwith College Transcripts. The Nursing Department will calculate cumulative GPA for multipletranscripts.Submit copy of High School Transcript or GED or Foreign Evaluation.Submit Skill Level Verification form from Counseling showing 7 in Reading & Writing, and 8 in Math.Must be college ready at time of application.Submit current San Jacinto College GPS report or Degree Evaluation report.Submit HESI A2 scores (must be taken within last 2 years)Applicants must achieve a score of 70% or higher in each category. Categories include: ReadingComprehension, Grammar, Vocabulary, and Mathematics. *Only 2 sets of scores may be submitted.Include copy of the HESI reports (Summary and Critical Thinking)Submit copy of Healthcare Insurance Card front/back10. Submit copy of Healthcare Provider CPR card from the American Heart Association (front & back)Must be BLS Provider and must not expire during the program11. Submit signed BON Statement Form and Emergency Contact Form included in this packet12. Submit signed statement of requirementsApplicant’s SignatureRevised 2/9/2021

Vocational Nursing Program Application – North CampusPlease Complete the Form in its Entirety and AccuratelyApplication must be typedDate Application for G00#:Semester / YearSSN (required by BON): - -Date of Birth: / /Full NameLastFirstMiddleMaidenAddressNumber/PO BoxStreetCityStateZipHome Phone Cell WorkActive Email (required must be typed)High School Diploma / GED / Span Tran (or other evaluation)Year Name of High School City/State/ CountryALL College(s) attended, including San Jacinto College, if applicable. (Please list all sealed transcripts you are submitting withthis application as well. Reminder- Transcripts must be within 60 days of application date)Name of SchoolCity/StateSealed Transcripts (Y/N)Courses in ProgressAre you or have you ever been on any academic probation or suspension?Have you ever applied to this nursing program before? YesNo If Yes, When?Have you attended any other school of nursing? YesNoIf Yes, When?Where? Name of school City/StateEntrance Date Exit Date Reason for leavingI, , acknowledge that the information on this application is true and correct to the best of myknowledge. I, , understand that any falsification of information provided will result indisqualification for admission.SignatureRevised 2/9/2021

In Case of Emergency(Must be Typed)Please list in the order you prefer us to call in case of emergency.NameRelationshipPhonePermission ToContact Yes NoInitials: Yes NoInitials: Yes NoInitials: Yes NoInitials:I understand that should my emergency contact change, it is myresponsibility to update my record in the nursing office.SignaturePrinted NameRevised 2/9/2021Date

Texas Board of Nursing Licensure EligibilityAll applicants must have a clear criminal background to be eligible for licensure with the Texas BON.To check your eligibility for licensure, please review the following:Have you 1.Been convicted of a misdemeanor?2.Been convicted of a felony?3.Pled nolo contendere, no contest, or guilty?4.Received deferred adjudication?5.Been placed on community supervision or court-ordered probation, whether or not adjudicated guilty?6.Been sentenced to serve jail or prison time or court-ordered confinement?7.Been granted pre-trial diversion?8.Been arrested or have any pending criminal charges?9.Been cited or charged with any violation of the law?10.Been subject of a court-martial; Article 15 violation; or received any form of military judgment, punishment, or action?NOTE: You may only exclude Class C misdemeanor traffic violationsExpunged and Sealed Offenses:While expunged or sealed offenses, arrests, tickets, or citations need not be disclosed, it is your responsibility to ensure the offense,arrest, ticket, or citation has, in fact, been expunged or sealed. It is recommended that you submit a copy of the Court Order expungingor sealing the record in question to our office with your application. Failure to reveal an offense, arrest, ticket, or citation that is not infact expunged or sealed, will at a minimum, subject your license to a disciplinary fine. Non-disclosure of relevant offenses raisesquestions related to truthfulness and character of the Nurse.Orders of Non-disclosurePursuant to Tex. Gov't Code §552.142(b), if you have criminal matters that are the subject of an order of non-disclosure, you are notrequired to reveal those criminal matters on this form. However, a criminal matter that is the subject of an order of non-disclosure maybecome a character and fitness of duty issue. Pursuant to other sections of the Gov't Code Chapter 411, the Texas Nursing Board isentitled to access criminal history record information that is subject of an order of non-disclosure. If the Board discovers a criminalmatter that is the subject of an order of non-disclosure, even if you properly did not reveal that matter, the Board may require you toprovide information about any conduct that raises issues of character. Are you currently the target or subject of a grand jury or governmental agency investigation? Has any licensing authority refused to issue you a license or ever revoked, annulled, cancelled, accepted surrender of, suspended, placedon probation, refused to renew a license, certificate or multi-state privilege held by you now or previously, or ever fined, censured,reprimanded or otherwise disciplined you? (You may exclude disciplinary actions previously disclosed to the Texas Board of Nursingon an initial or renewal licensure application) *Within the past five (5) years have you been diagnosed with, treated, or hospitalized for schizophrenia and/or a psychotic disorder, bipolar disorder, paranoid personalitydisorder, antisocial personality disorder, or borderline personality disorder? (You may answer "No" if you have completed and/or are in compliance with TPAPN formental illness OR you've previously disclosed to the Texas Board of Nursing and have remained compliant with your treatment regimen and have had no furtherhospitalization since disclosure)*In the past five (5) years, have you been addicted or treated for the use of alcohol or any other drug? (You may answer "No" if you have completed and/or are in compliancewith TPAPN) *Pursuant to the Occupations Code §301.207, information, including diagnosis and treatment, regarding an individual's physical or mental condition,intemperate use of drugs or alcohol, or chemical dependency and information regarding an individual's criminal history is confidential to the same extent that informationcollected as part of an investigation is confidential under the Occupations Code §301.466.Revised 2/9/2021

Texas Board of Nursing Statement FormName:(Please Type)Please read the following statements and sign below.The applicant who has been convicted of a felony, implicated in substance abuse or involved in activitiesconsidered inappropriate by the Board of Nursing for the State of Texas is not eligible to apply to theVocational Nursing Program until he or she has received a declaratory order from the Texas Board of Nursinggranting permission to write the NCLEX- PN. This form is available at The Board’s statement of eligibility must be submitted tothe Vocational Nursing Department Chairperson/Coordinator.The prospective student is responsible for obtaining a “Petition for Declaratory Order.”I, , have read and understand this statement. Date:My signature acknowledges that I have read the Texas Board of Nursing Licensure eligibility statements.I further acknowledge that I have initiated the Declaratory Order process, if applicable, and willcommunicate the outcome to the nursing program.*** SignatureDateTexas Board of Nursing Roster Submission StatementThe program will submit the names of qualified applicants to the Texas Board of Nursing per the TexasBoard of Nursing’s guidelines. This process initiates the background check process. Students will becontacted via email with directions for fingerprinting.I, , have read and understand this statement. Date:My signature acknowledges that I have read the Texas Board of Nursing Roster Submission Statement.I further acknowledge that my information will be sent to the Texas Board of Nursing based on theBoard of Nursing’s guidelines.*** SignatureDate***A signature is required ***The signature portions of the application must be signed not typed.Typing the signature portions will invalidate your application.Revised 2/9/2021

Acknowledgement of Requirements Upon AcceptanceApplicants who are accepted into the program must complete the following: Attend the mandatory Vocational Nursing Student Orientation: Dates provided in AcceptanceLetter.Submit proof of completed immunization status to program and/or CastleBranch (See list below).CPR - Submit completion of American Heart Association BLS (Health Care Provider) to CastleBranch.BON clearance –Original Blue Card or Outcome Letter (along with a copy of same for our records)must be submitted to Vocational Nursing Office at orientation.Submit copy of Healthcare Insurance CardComplete Physical Examination (Physical form issued at time of orientation)Required Immunizations Include:Tetanus/Diphtheria /Pertussis (Tdap) [within the past 8 years]TB (PPD) skin test, Chest X-ray, or Quantiferon test [within the past year]Seasonal flu vaccine (within the last year). Flu mist is not accepted.Titers that show immunity for the following:MMR titerVARICELLA titer (No history of disease will be accepted.)HEPATITIS B titer (A “fast track” series will not be accepted.)HEPATITIS C Titer (this titer should be negative)My signature acknowledges that I have read the requirements to complete, if accepted.I further acknowledge that I will comply with the requirements. Failure to comply will result in denialto the program.*** SignatureRevised 2/9/2021Date

Vocational Nursing Admission Scoring RubricTHE MINIMUM SCORE REQUIRED TO APPLY IS 4. THE MAXIMUM SCORE POSSIBLE IS 321. GRADES:A 5Course: BIOL 2301/2101 is a Pre-Requisite for the VNSG Programa. BIOL 2301 AND BIOL 2101 OR BIOL2401date of courseb. BIOL 2302 AND BIOL 2102 OR BIOL 2402date of courseGradesA BA BB 3 C 1IP 0PointsCCIPIPIf you have failed out of a vocational nursing program, you must wait 1-year from the date of your last failed course to apply.Example: Failures in Fall 2018 or later render you ineligible for Fall 2019 enrollment.**Course in progress (IP) receive no points.**If BIOL 2301/2101 was repeated within the last 5 years due to course failure (D or F), there will be a 2-point reduction.3. HESI EXAMComposite Score:Note: If you’ve taken the HESI more than once, add the highest scores on the four sections we require- thendivide by four to obtain your composite score. All categories must be 70 or greater.1) Reading Comprehensiona) Meaning-Word Useb) Conclusionsc) Implicationsd) Understanding2) Grammar3) Vocabulary4) MathComposite Score70 – 75% - 2 points76 – 80% - 3 points81 – 85% - 4 points86 – 90% - 6 points91 - 95% - 8 points96 – 100% - 10 pointsCritical Thinking Score:4. Overall GPA : San Jacinto College (if applicable) & all other schools:If more than one school was attended – acceptance committee will calculate your GPA.2.25 – 2.49 – 2 points2.50 – 2.75 – 4 points2.76 – 2.99 – 6 points3.00 – 3.50 – 8 points 3.51 -10 points5. Veterans or Certified Nursing Assistants may receive an additional two (2) points with appropriatedocumentation. Veterans- DD-214 showing an Honorable Discharge CNAs- Current certification and verifiable, current work experience.**A maximum of two (2) points will be given. For example, a veteran who is a CNA will only receive 2 points,not four.**Revised 2/9/2021

Revised 2/9/2021