LPN Application Form

Academy of Healthcare Excellence does not discriminate in admissions or access to its program and activities on the basis of race/color, national origin, ethnicity, religion/creed, disability, age, marital status, sex, sexual orientation or veteran's status. Academy of Healthcare Excellence is committed to complying with all state and federal laws prohibiting discrimination. Applicants to the Licensed Practical Nursing Program must have the ability to satisfactorily meet the cognitive, physical and emotional requirements of the Nursing curriculum.
LICENSED PRACTICAL NURSE PROGRAM

APPLICATION FOR ADMISSION
Campus: *
Which campus do you want to attend?
Class schedule:*
Day: Monday - Friday [8:30am - 3:00pm] Evening: Monday - Friday [4:30pm - 11:00pm]
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
U.S. Citizen:
If No, are you a permanent resident?
Emergency Contact Name:

First NameLast Name
Emergency Contact Relationship:
Emergency Contact Phone Number:
Please enter a valid phone number.

Gender, Birth Date and Ethnicity.

Responses to Gender, Birth Date and Ethnicity and Race are voluntary and will be kept confidential. Failure to finish this information will not adversely affect the status of this application.
Gender
Birth Date

MonthDayYear
Date
Ethnicity/Race
Academic History: List all Colleges, Universities and Institutions attended, including High School. List most recent first.
Name, Location, Degree, Date.

Employment History.
Veteran of the Armed Forces?
Employment History:
Please list: Occupation/Job Title, Employer, Start/End Dates from current to previous.
List any special recognitions/awards given for academic achievement:
How did you learn about Academy of Healthcare Excellence?
Have you previously applied to Academy of Healthcare Excellence LPN Program?
Are you applying for readmission?
If yes, What term are you reapplying for?
Are you a previous graduate of Academy of Healthcare Excellence?
If yes, which program did you complete?

Education Credentials (GED, High School Diploma & College/University Credits)
Do you have a United States or U.S. territory High School Diploma or GED?
If you have a Foreign / International High School Diploma, what Country is your Diploma from? (Type "N/A" or not applicable if this does not apply to you.)
EDUCATION CREDENTIALS OVERVIEW
(STUDENT OFFICIAL TRANSCRIPTS OR DIPLOMA)

1. Official High School and/or GED transcripts - Foreign/International Diplomas must have degree evaluated with www.wes.org - Foreign/International High School Diploma = $111 (Basic Package) | iCap Package = $160 (online storage package)

2. Official transcripts from all previously attended colleges - Foreign/International Credits or Diplomas must have degree evaluated with www.wes.org - Foreign/International College/University = $176 (Basic Package) | iCap Package = $225 (online storage package)

Student Requirements
A $30.00 non-refundable application fee must be submitted for this application.

Your application will not be processed without this fee.
Application Requirements: If accepted, the following will be required.
- Official High School and/or GED transcripts
- Official transcripts from any and all previously attended Colleges
- A copy of your pre-entrance test results TABE
- Health Insurance (recommended, not required)
- Student Malpractice Insurance Policy (www.NSO.com)
- Drug Test Screen (if clinical site requires)
- Criminal Background check
- CPR
- (1) Letter of references, (1) employer and (1) academic. High school senior should obtain (1) Letter from your guidance counselor. (2 references recommended up to 3 accepted)
- Health packet of annual Physical, 2-step PPD or TB Gold, Flu Vaccine as required.
CLINICAL REQUIREMENT OVERVIEW

(CLINICAL HEALTH REQUIREMENTS FOR ROTATIONS) – DUE IF ACCEPTED INTO THE PROGRAM
- Annual Physical (Due every 12-months even when enrolled as active student)
- Sept 1st – April 30th Need proof of current influenza vaccination (Flu Shot) *subject to change pending clinical site request.
- Classes starting on or after 05/01: Do not need to submit influenza vaccination proof unless otherwise notified.
- Proof of negative TB test/results dated within 1 year. Can accept either of the 3 tests listed:o 2 step PPDo TSPOTo Quantiferon
- TB Gold For anyone with a positive TB test/results, we will need a copy of chest x-ray with negative results dated within 1 year.
BACKGROUND CHECK NOTICE***

(BACKGROUND CHECK NOTICE) ***Please note that Academy of Healthcare Excellence does not require a background check to be accepted into the program but will be required to undergo a background check through the state of New Jersey when applying for state LPN License. The school will not be held responsible for background reports that deem applying student ineligible to receive a LPN license for State of New Jersey or any other state applicant may apply for.
Application Fee*
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AHE-LPN Application
$30.00

Total

$0.00

Payment Methods

Debit or Credit Card

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LICENSED PRACTICAL NURSE PROGRAM

Gender, Birth Date and Ethnicity.

Employment History.

Education Credentials (GED, High School Diploma & College/University Credits)

EDUCATION CREDENTIALS OVERVIEW

Student Requirements

A $30.00 non-refundable application fee must be submitted for this application.

BACKGROUND CHECK NOTICE***