APPLICATION FOR RMA NURSING PROGRAM

Complete the following application form
IDENTIFICATION

First Name

Middle Initials

Last Name

Date of Birth

Gender
 Male Female

Marital Status

Nationality/Citizenship

Ethnicity

Social Security Number

Electronic acknowledgement to submit a copy of social security card (Initials)

Date to submit a copy of social security Card

CONTACT INFORMATION

Primary Phone Type

Primary Phone Number

Secondary Phone Type

Secondary Phone Number

Contact Email Address

Address

City

Zip Code

State

Do you have a Valid Driver’s License/Government-Issued Photo ID ?
 Yes No

Submit Valid ID

PROGRAM OF ENROLLMENT

Program of Interest
 CNA LPN LPN-to-RN

Time of the day
 Morning Classes Evening Classes

Enrollment Period

Enrollment Year

EMERGENCY CONTACT

Emergency Contact Person

Emergency Contact Person Relationship

Emergency Contact Phone

REFERENCES (Must be someone in a professional setting)

First Reference Person’s Names

First Reference Person’s Relationship to applicant

First Reference Person’s Contact Phone

First Reference Person’s Contact Email Address

First Reference Person’s Physical Address

First Reference Person’s Occupation

Second Reference Person’s Names

Second Reference Person’s Relationship to applicant

Second Reference Person’s Contact Phone

Second Reference Person’s Contact Email Address

Second Reference Person’s Physical Address

Second Reference Person’s

Occupation

Third Reference Person’s Names

Third Reference Person’s Relationship to applicant

Third Reference Person’s Contact Phone

Third Reference Person’s Contact Email Address

Third Reference Person’s Physical Address

Third Reference Person’s Occupation

PRIOR EDUCATION AND TRAINING

Prior Education

Do you have a high school qualification
 Yes No

Which high school did you go to? (Include when started and ended)

Submit proof of your high school qualification (High School Diploma or GED)

Prior Training

Do you have a nursing aide certification (CNA)
 Yes No

Submit proof of your CNA Certificate

Do you have a CPR Certification
 Yes No

Submit proof of your CPR Certification

Which Practical Nursing School did you go to (for LPN-RN Applicant), (Include when started and ended)?

Electronic acknowledgement to request copy of transcripts (LPN and Prerequisites)

Do you have a Valid PN License (for LPN-RN Applicants)?
 Yes No

License Number

Issued State

LPN License Expiring Date

Do you have any of the following prerequisites on any of the following courses (For LPN-RN Applicants)?

 College Algebra English Psychology Sociology Microbiology

College Algebra

English Composition

Introduction to Psychology

Introduction to Sociology

Microbiology

Electronic acknowledgement to take Nursing School Entrance Examination (Cost $75/Examination)

Schedule date to take Entrance Examination

Do you need review before taking entrance Examination?
 Yes No

EMPLOYMENT HISTORY

Do you currently work at a long-term health facility?
 Yes No

Life experience/training in relation to the Health Care Field (Include source, date of training and any certification/diploma earned):

Employed by, Years Employed:

CRIMINAL BACKGROUND CHECK

Do you have a Criminal Record?
 Yes No

If yes, on what offense

Electronic acknowledgement to do background check

Schedule date to do background Check (Mon - Fri, 9am-5pm)

MEDICAL HISTORY

Submit Physical Examination from a qualified health personnel within pass 1 year

Submit TB Skin Test Results from a qualified health personnel within pass 1 year

Submit Immunization Records from a qualified health personnel within pass 1 year

"I certify that the information on this application is complete and accurate to the best of my knowledge. I understand that misrepresentation of facts on this application may be cause for refusal of admission, cancellation of admission or suspension from RMA. By signing and dating this application I agree to abide by the policies and regulations of RMA

Date

Call the office number: (419) 534-2371 to schedule your entrance test if you are interested in RMAs CNA/STNA, PN or LPN – RN Program.