ADN Application NCK Tech ADN Application (RN-2nd year program) I am applying to the ADN Program on the following campus?* Beloit Campus Hays Campus Both Campuses (I would like to be considered for either campus) First Name* Middle Name Last Name* Maiden Name (if applicable) Date of Birth MM slash DD slash YYYY Current Address* Street Address City State / Province / Region ZIP / Postal Code Permanent Address (if different than current address) Street Address City State / Province / Region ZIP / Postal Code Email Address* Home Phone*Cell Phone*What is your primary language?*Please choose oneEnglishSpanishOtherOptional InformationEthnicity White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Islander Multiracial Other If other, please specify: Gender Male Female Choose not to indicate Self-Reported Pre-Requisite InformationYou will need to send your official transcript(s) to NCK Tech to make your application process complete. Information provided in this section does NOT take the place of official transcripts. Please indicate if the course is complete (with a C or better), in progress, if you have not yet taken the course, or if you are unsure if the course you took at another institution is transferrable as the same course.Human Anatomy & Physiology with Lab (5 credit hrs)*Please choose oneCompletedIn ProgressNot yet takenUnsureGeneral Psychology*Please choose oneCompletedIn ProgressNot yet takenUnsureHuman Growth & Development*Please choose oneCompletedIn ProgressNot yet takenUnsurePrinciples of Nutrition*Please choose oneCompletedIn ProgressNot yet takenUnsureIntermediate OR College Algebra*Please choose oneCompletedIn ProgressNot yet takenUnsureEnglish Composition I*Please choose oneCompletedIn ProgressNot yet takenUnsureMicrobiology with Lab*Please choose oneCompletedIn ProgressNot yet takenUnsureAre you IV Therapy Certified?*Please choose oneYesNoIn progressHiddenMonth/Year of initial LPN/LVN Licensure*Month/Year of initial LPN/LVN Licensure (if you don't know exact date please use the first of the month) MM slash DD slash YYYY State of current LPN/LVN licensure EducationHigh School Name* High School Graduation Year*Please enter a number from 1900 to 2025.Name of Previous College Attended (if applicable) - #1 Last Year AttendedPlease enter a number from 1900 to 2025.Name of Previous College Attended (if applicable) - #2 Last Year AttendedPlease enter a number from 1900 to 2025.Name of Previous College Attended (if applicable) - #3 Last Year AttendedPlease enter a number from 1900 to 2025.Consent* I certify that to the best of my knowledge all statements that I have made on this application are complete and true. Additionally, I have completed the items on this application in their entirety and will provide NCK Tech the documents required as a condition of admission and enrollment.Name* First Last Today's Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ
