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Nursing Program Application

Applicants for the Fall 2015 Nursing Program are required to complete this supplemental Nursing application. Reference forms can be found on the Admissions web page. If you are new to Clinton Community College you must also complete our free general Clinton application and submit an official copy of your high school transcript. A GED will be accepted in lieu of a high school transcript. If you have previously attended other colleges, you must have official academic transcripts sent from each of those institutions. If you have previously attended or are currently attending Clinton Community College, you are not required to re-submit these documents. Please be mindful of the February 1st application deadline and be responsive to status letters arriving by mail.



Submission deadline February 1


First Name *


Last Name *


Social Security Number *


Mailing Address: PO Box or Street Address *


City *


State *


Zip *


Telephone Number (XXX) XXX-XXXX: *


Email Address:


Are you an U.S. Citizen *
 Yes
 No


Date of Birth: *


List below information concerning High School or other secondary school attended. Include Name of School, Location, Dates of Attendance and Diploma received. *


Have you previously made an application to Clinton Community College? *
 Yes
 No


Have you previously attended Clinton Community College (including High School - College Advancement Program) *
 Yes
 No


Are you currently attending Clinton Community College (including High School - College Advancement Program)? *
 Yes
 No


List below information concerning ALL colleges, universities, or other post secondary schools attended. Include Name of School, Location, Dates of Attendance and Degrees received.


If previous college program was not completed, state reason. Applicants who have attended another school of nursing, RN or LPN, and left prior to completion must request a letter from the Nursing Program Director to be sent to the Clinton Community College's Nursing Program Director indicating the circumstances under which the student withdrew.


Other educational, travel, and/or community service experience:


Do you have any prior health related experience (nurse aide, medic, LPN, etc.) ? If Yes, please describe and include length of service.


How would you rate your own general health? *
 Excellent
 Good
 Fair
 Poor


Have you ever been found guilty of a crime (felony or misdemeanor)? *
 No
 Yes


If yes, please elaborate:



Give the NAME, ADDRESS, and OCCUPATION of three persons, not relatives, who know you and can give information about you. For example, you should include a recent teacher, counselor or employer. Supply each of these persons with a personal reference form. Be sure to print your name clearly on the reference form. The reference form should be returned to the Admissions Office, Clinton Community College, 136 Clinton Point Drive, Plattsburgh NY 12901.


Reference #1 *


Reference #2 *


Reference #3 * *


In the space below, please write an account of (1) your experiences and activities since you last attended school, if more than six months have elapsed, (2) all the things you have accomplished that have given you the greatest satisfaction, (3) what you most enjoy doing in your leisure time, (4) your reasons for selecting nursing as a career, (5) any special reason for desiring to entering this school, and (6) your plans and aspirations for the future. Include any data or facts relative to your application which you feel are important and which may not have been covered elsewhere. *



Submission deadline February 1