Application for Admission to the Camp Phlebotomy Program
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Today's Date *
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First Name *
Last Name *
Email
Student ID number
Date of Birth
Address
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
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
Educational History
High School
College
Special Training
Other
Employment History
Date
Employer #1
Employer's Address
Supervisor's Telephone #
Date
Position
Employer #2
Employer's Address
Supervisor's Telephone #
Career Goals
Explain why you are interested in this program
What personal attributes or skills do you bring to this program?
What obstacles do you have in completing this program?
Describe how you plan to overcome these obstacles. Include assistance that you would like to request of Paul D. Camp Community College.
Have you committed, or been convicted of, any act which is a felony under the laws of Virginia or the United States or any act which is a misdemeanor under such laws and involves moral turpitude? (Moral turpitude is a legal concept that refers to "conduct that is considered contrary to community standards of justice, honesty or good morals). Explain.
In the space below you may give additional information, which you feel is pertinent to your application. You may include additional employment history, volunteer work, certificates, scholastic awards, work achievements, and/or professional organizations.
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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