NEW COLLEGE APPLICATION FORM

COLLEGE APPLICATION FORM

Thank you for your interest in becoming associated with Bethesda College of Health Sciences Nursing or Radiography Program. Please complete this application in full to help us learn about your experience and abilities. Applicants are accepted into the program without regard to race, color, religion, national origin, sex, age, handicap or other similar factors that are not program-oriented.

General Information

First name

Last name

Middle Name

Gender

Birth Date

Social Security Number

XXX-XX-XXXX

Former/Maiden Name

Street

City

State/Province

Zip/Postcode

Country

Home Phone

Cell Phone

If different from above

Mailing Address

used in transcript request form

City

used in transcript request form

State

used in transcript request form

Zip

used in transcript request form

Education

High School/GED

High School Name or place where GED obtained

Graduation or Completion (Month/Year)

City

State

College/Institution:#1

Name of Institution/College

City

State

Degree Received

Date(s) attended: From

(Month/Year)

Date(s) attended: To

(Month/Year)

College/Institution:#2

Name of Institution/College

City

State

Degree Received

Date(s) attended: From

(Month/Year)

Date(s) attended: To

(Month/Year)

College/Institution:#3

Name of Institution/College

City

State

Degree Received

Date(s) attended: From

(Month/Year)

Date(s) attended: To

(Month/Year)

College/Institution:#4

Name of Institution/College

City

State

Degree Received

Date(s) attended: From

(Month/Year)

Date(s) attended: To

(Month/Year)

Comment

Have you ever been convicted/charged of a felony or misdemeanor; or pleaded nolo contendere (no contest) to a felony or misdeameanor; or pleaded nolle prosequi (prosecution abandoned); or pleaded guilty to a felony or misdemeanor; or been found guilty of a felony or misdemeanor or have felony or misdemeanor charges pending against you? (Include any and all instances of the foregoing even if adjudication was withheld).

Convicted/charged of a felony or misdemeanor?

Yes No Not Selected

If yes, describe in full

Date

Degree Information

(Admission to the college does not guarantee admission to your desired program)

Associate Degree

How did you hear about the Program?

Applicant Information

In Case of Emergency

Contact Name

Home Phone

Street

City

State

Zip Code

Is English your primary language?

Yes No Not Selected

If no, Primary Language

Do you have any health related conditions, or any other physical or mental condition or handicap, which may limit your ability to safely and efficiently perform all duties, associated with a Nursing/Radiography Student?

Yes No Not Selected

Do you smoke or use other tobacco products?

Yes No Not Selected

Please list any Licenses/ Training/ Skills/Aptitudes/Qualifications/ Certifications:

Baptist Health South Florida (BHSF) Employment Disclosure

Current Baptist Health employees not in good standing, or former Baptist Health employees who are not eligible for rehire are ineligible to participate in the Program.

Are you now or have you ever been a BHSF employee?

Yes No Not Selected

Employment Information

Please start with the most recent job and fill out the employment information in descending order.

If you are currently employed, may we inquire of your present employer?

Yes No Not Selected

Employment # 1

Company Name

Telephone

Job Title

Employed From Date(Month/Year)

Employed To Date (Month/Year)

Address

Name of Supervisor

Reason for Leaving

Brief Description of your Duties

Employment # 2

Company Name

Telephone

Job Title

Employed From date (Month/Year)

Employed To Date (Month/Year)

Address

Name of Supervisor

Reason for Leaving

Brief Description of your Duties

Employment # 3

Company Name

Telephone

Job Title

Employed From date (Month/Year)

Employed To Date (Month/Year)

Address

Name of Supervisor

Reason for Leaving

Brief Description of your Duties

Professional/Employment Reference Details

Reference # 1

Last Name

First Name

Address

Phone Number

Business/Occupation

Years Acquainted

Reference # 2

Last Name

First Name

Address

Phone Number

Business/Occupation

Years Acquainted

Reference # 3

Last Name

First Name

Address

Phone Number

Business/Occupation

Years Acquainted

Please submit a 250-word essay regarding interest in becoming a Nurse/Radiographer. (Please put your full name on your essay and make sure its in Word format before uploading your document)

250 Word Essay regarding interest in becoming Nurse/Radiographer.

Application & Background Check Certification

I authorize reference checks and background investigation of all statements contained in this application. I understand my attendance in BETHESDA COLLEGE OF HEALTH SCIENCES NURSING/RADIOGRAPHY PROGRAM is contingent upon this verification. I further understand that my training may be terminated if I fail to comply with the Program and College policies and procedures. I also understand and agree that all items of College property will be returned to the school or paid for prior to leaving BCHS. I understand that if I fail to answer any question; falsify the answer to any questions; fail to provide information which might make any answers to this application misleading; or enter incorrect information; this alone may result in a refusal to accept me in the program or result in my dismissal from the program if I have already been accepted.

I authorize the above Statement

Yes No Not Selected

Background Investigation - Acknowledgment & Authorization

NOTICE AND ACKNOWLEDGMENT
(IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEGMENT)

NOTICE REGARDING BACKGROUND INVESTIGATION

BETHESDA COLLEGE OF HEALTH SCIENCES may obtain information about you from a consumer reporting agency for enrollment purposes. This request may make you the subject of a e-consumer report which may include information about your character, general reputation, criminal record, employment, education, driving record, and/or other characteristics of your current and past history. This request may involve personal interviews with sources such as your current and past employers, friends, or associates. Requests may be obtained before acceptance to the program and, if you are accepted, throughout the program, and after termination for wrongful activity in direct relation to this program, as prescribed by law. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Credential Check Corp. will perform searches from various sources and compile the results in to a final report to our client. Sources will vary by search type, may include information from third parties, and are performed as prescribed by law, the Fair Credit Reporting Act (FCRA), and state law governing employment background screening/investigation. Credential Check Corp. is located at P.O.Box 4504 Troy, MI.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of these documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am accepted in the Nursing or Radiography program, and throughout my education in this program. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Credential Check Corp, or another outside organization acting on behalf of Credential Check Corp. I agree that a facsimile (Fax) or photographic copy of this Authorization shall be as valid as the original.

I Authorize and Acknowledge the above statement

Yes No Not Selected

Drivers License #

The application fee is due at the time of submission of the application. The application will not be deemed "Submitted", and review of the application will not begin, until the applicant has paid the application fee.

I agree with the above mentioned Statement

Yes No Not Selected

Applicant E-Signature

(First, Middle, and Last)

Date

Parent/Guardian E- Signature

(if applicant is under 18 years old.)

By signing this form I am certifying that all statements are true and accurate to the best of my knowledge. I have included the non-refundable college application fee of $100.00 made through Authorize.net. Also, I understand that if it is found that my records or any other information provided at the time of enrollment is false, I may be expelled from the college without a refund of any fees paid.