Application for Admission to the Camp Nurse Aide Program
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Today's Date *
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First Name *
Last Name *
Email *
Date of Birth
Address
Home Phone
Cell Phone
Work Phone
Student ID number
Camp History
Have you attended Paul D. Camp Community College in the past?:
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Approximately how long ago did you last attend?
Have you taken Camp placement tests in the last 3 years?
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If you have not taken classes at Camp within the last three years, you should complete a new Application to the College and take the placement tests again
Highest level of education completed
Why are you interested in becoming a Nurse Aide?
Have you ever worked as a nurse aide before?
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If so, where and for how long?
How did you become aware of our program?
Have you ever been convicted of any crime (misdemeanor or felony) other than a minor traffic offense?
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If yes, please list the charge, date and disposition. A criminal background and drug screening is required on admission.
Application Checklist
Have you ever submitted an application for the College or are you submitting one with this application?
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Have you submitted 2 official copies of your high school or GED scores to the Nursing Office?
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Have you taken the College placement tests?
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Have you taken any developmental courses recommended by placement tests that are needed to be ready for English 111?
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Did you indicate the semester you prefer to take the course on the other side of this application sheet?:
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If you answered “no” to any of the above questions, you need to be aware that your application is not yet complete.
Please read carefully the following paragraphs:
I certify that this information is accurate and complete. I understand that giving incomplete or false information is grounds for denial of the application. I authorize Paul D. Camp Community College to request such information as necessary to verify my qualifications/suitability for the Nursing Program for which I have applied. I hereby release from all liability or damage those individuals who provide information related to my education or character and waive any rights of inspection of such information.
Nursing students are involved in the provision of direct patient care in medical facilities. Certain medical facilities require all nursing students to have a Virginia State Police criminal history and sex offender’s crimes against minors background investigation completed prior to the provision of patient care. Some facilities may also require drug testing for nursing students. Any student found guilty of a misdemeanor or felony prior to or during nursing education will be required to request an Exemption from Disqualification from each of the medical facilities to which they may be assigned during the program. If an exemption is not granted by the medical facility, the student will be unable to complete the requirements for the nursing program, and will not be permitted to progress through the program. Students will be required to submit similar documentation to the Virginia Board of Nursing when making application to take the registered nursing exam in Virginia. The Board of Nursing can deny licensure to any applicant who has filed false credentials, who has falsely represented facts on the application for licensure, and/ or who has committed a felony or misdemeanor. In addition, certain health care facilities may not hire individuals who have committed a felony or misdemeanor.
I understand that the responsibility for providing all transcripts and documentations to the nursing office lies with the applying student. Failure to provide required documents will be grounds for non-acceptance. I understand that the following documents are required:
1. Official transcripts from high school or GED scores, colleges, and other higher education facilities
2. Evidence of U.S. citizenship or authorization to reside in the United States
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