Nursing Student Enrollment Form

NURSING STUDENT ENROLLMENT FORM

Student Information

Student Name:

Date of Birth:    Student ID (if assigned):    Grade/Program Year:

Program Enrollment Details

ADN (Associate Degree in Nursing)    BSN (Bachelor of Science in Nursing)    PN (Practical Nursing)    Bridge/Accelerated Certificate

Program Start Date:    Expected Completion Date:

Enrollment Status: Full-time    Part-time    Campus/Site:

Contact Information

Education & Transcripts

Graduation Year:    Cumulative GPA:

Official transcripts attached: Yes    No

Licensure, Certifications & Health Requirements

Current professional licensure or certification:

Hepatitis B series completed    MMR (Measles, Mumps, Rubella)    Varicella    Tdap    TB test (PPD or IGRA)

I have a medical condition or allergy that may affect clinical participation: Yes    No

Background Check & Drug Screening Consent

As a condition of enrollment and clinical placement, the student must submit to criminal background checks and drug/alcohol screening. The student authorizes release of results to the program administration and clinical affiliates. A positive result or disqualifying record may result in denial of clinical placement or dismissal from the program.

I consent to required background checks and drug/alcohol screening as described above.

Have you ever been convicted of a felony or misdemeanor, or are there pending criminal charges against you? Yes    No

Clinical Requirements & Acknowledgments

Clinical participation requires compliance with facility policies, satisfactory health clearance, immunization and CPR/BLS status, and demonstration of requisite skills. Failure to meet clinical requirements, or violation of patient confidentiality or facility policies, may result in removal from clinical rotations and dismissal from the program. The student is responsible for transportation to clinical sites and for any associated costs.

The program requires professional liability coverage as a condition of clinical placement. The student shall secure and maintain coverage if requested by the program or clinical partner.

I acknowledge the attendance and clinical performance policies and understand noncompliance may result in academic penalty or dismissal.

I acknowledge my obligation to maintain patient confidentiality in accordance with facility policies and understand that breaches may lead to dismissal and legal action.

I acknowledge the program's drug and alcohol testing policy and agree to comply with testing as required.

Emergency Contact

Financial Agreement

Tuition and fees constitute a binding financial obligation upon enrollment. The student is responsible for payment of all tuition, fees, and any costs associated with clinical placements unless otherwise specified in written financial aid or scholarship agreements.

Payment option: Full Payment    Installment Plan (specify)

I acknowledge the institution's refund policy for withdrawal or dismissal and accept financial responsibility for charges assessed up to the date of withdrawal or dismissal.

I acknowledge and accept the financial terms and refund policy.

Records Release & Privacy

I authorize the release of academic and health records to clinical affiliates for the purpose of placement and compliance review. I understand the program will maintain my student records in accordance with institutional policy.

Designated person(s) to receive information (if any):

Previous Nursing Education / Licensure

Certification and Signature

By signing below I certify that the information provided on this form is complete and accurate to the best of my knowledge. I understand that falsification, omission, or failure to disclose pertinent information may result in denial of admission or dismissal. I agree to comply with program policies, clinical site requirements, and all applicable professional standards while enrolled.

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