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RIBN Program

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RIBN Program

Hickory Collaborative RIBN Application

Personal Information

First Name: *

Middle Name:

Last Name: *

Gender: *

Male

Female

Mailing Address: *

City: *

State: *

Zip Code: *

Home Phone: *

Cell Phone:

Work Phone:

Email: *

Are you a North Carolina resident?: *

Yes

If "Yes," for how long?: *

What county?: *

Are you a United States citizen?: *

Yes

If "No," of what country are you a citizen?: *

Are you a legal resident of the U.S.?: *

Yes

Date of Birth: *

Marital Status: *

Additional Information

The following information is used for statistical purposes.*

*Responses to questions regarding race, national origin, and ethnic heritage are optional. Questions regarding citizenship must be answered. Information gathered will be used only for statistical purposes and will not be used in any discriminatory manner.

Do you consider yourself to be Hispanic/Latino?:

Yes

In addition, select one or more of the following racial categories to describe yourself:

Native American or Alaska Native

Asian

Black or African-American

Native Hawaiian or other Pacific Islander

White

Education

List the high schools and colleges/universities (if applicable) that you have attended. (Have official transcripts from all schools attended sent to Lenoir-Rhyne University, Office of Enrollment Management, RIBN Advisor, Box 7227, Hickory, NC 28603 USA):

Name of Institution #1: *

Address : *

Telephone: *

Dates Attended: *

Name of Institution #2:

Address :

Telephone:

Dates Attended:

Name of Institution #3:

Address :

Telephone:

Dates Attended:

Are you eligible to return to your last school?: *

Yes

If "No," please explain: *

*Information for reporting to the North Carolina Board of Nursing only
NOTICE - Students must meet all requirements to be considered for admission into the Hickory Collaborative RIBN Program. Meeting all of the requirements does not guarantee admission into the program. Admission to the program is highly competitive. After meeting all of the admission requirements for both Lenoir-Rhyne University and the Community College selected on the application, applicants will be ranked numerically. A detailed description of how the point system works is in the admission criteria packet as well as online at http://www.lr.edu/admissions/RIBN.

Hickory Collaborative RIBN Checklist

Please use this checklist for items that MUST be submitted after filling out this online application!

Community College Information

Please select the community college you plan to attend as part of the Hickory Collaborative RIBN Program: *

Caldwell CC &TI

Catawba Valley CC

Mitchell CC

Wilkes CC

Western Piedmont CC

Year you plan to enroll: *

Semester you plan to enroll: *

SAT or ACT

Have you taken the SAT?: *

Yes

N/A

If "No," are you planning to take the SAT?:

Yes

Have you taken the ACT?: *

Yes

N/A

If "No," are you planning to take the ACT?:

Yes

The following High School courses are Required for acceptance into the Hickory Collaborative RIBN Program:

Four (4) units of English
Two (2) units of a language other than English (MUST be progressive)
One (1) unit of American History
Three (3) units of mathematics (Algebra I, Algebra II, & Geometry). Other math such as Statistics is encouraged but not required.
One (1) unit of a laboratory science (other than Chemistry)
One (1) unit of Chemistry (Required) – must be within last 5 years

Courses MUST be listed on High School Transcript

TEAS-V Exam
In addition to the required high school courses, students will be given permission to take the TEAS-V Exam by one of the RIBN Advisors.

Note: Failure to answer the following questions fully will delay the processing of your application:

1. Have you been convicted of a criminal offense other than a minor traffic violation?: *

2. Are there any criminal charges pending against you at this time?: *

3. Have you ever been dismissed, suspended, or placed on probation for disciplinary reasons by any high school or college/university?: *

4. Have you ever been dismissed, suspended, or placed on probation for academic reasons by any high school or college/university?: *

If you answered "Yes" to any of the four questions above, please explain the circumstances:

I certify that the information on this application is correct and complete.

Today's date: May 24, 2013

Admissions

Everything you need to apply for admission is right here.