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Admission Application to an IHS College
Trinity College of Nursing & Health Sciences
Student Services
2122 25th Avenue
Rock Island, IL 61201
con@trinityqc.com
(309) 779-7700
Fax: (309) 779-7796
http://www.trinitycollegeqc.edu/
Fill out the application and:
  1. Submit application online with a $50 non-refundable fee.
  2. OR Print a copy and return by mail with a $50 non-refundable fee to Trinity College of Nursing & Health Sciences.
  3. If you are re-applying, please select the appropriate application fee in the Application Payment section. There is a $15 non-refundable re-application fee. Your application cannot be processed without payment.
Instructions:* Signifies optional fields or sections where information not required
Personal Information
Name (First Middle Last):
First:
Middle:
Last:
Application Date
Saturday Apr 19, 2014 at 2:34:47 PM
Have you ever had another name(s)?
(i.e. Maiden)


If yes, give name(s):
Social Security
Your social security number is being collected in compliance with the Dept of Education, the federal financial aid regulations, Federal Trade Commission and the truth and lending laws. Your personal identification number will be kept confidential in compliance with the FTC and the Gramm-Leach-Gliley Act (GLB).
Number
(000-00-0000)

E-mail Address
Date of Birthmm/dd/yyyy
Gender
Male Female
Are you a first Generation student?
(Neither of your parents completed a college degree)
Yes No
Current Street Address

Current City:
Current Zip:
Number of Months at Current Address:
Current State: Current County:
Is your Permanent Address the same as your Current Address?
Permanent Street Address

Permanent City:
Permanent Zip
State: Permanent County:

Primary Phone
555-555-5555
Work Phone (optional)
555-555-5555
Cell Phone (optional)
555-555-5555
Country of Citizenship:
USA Other, please specify:
If you are not a U.S. citizen, are you a permanent resident of the U.S.?
Yes No
If NO, enter your Alien Registration Number
A-Trinity College of Nursing & Health Sciences does not issue an I-20.
If you are not a U.S. citizen, are you a lawfully admitted alien?
Yes No
If you are not a U.S. citizen, what is your visa type? Student Exchange Visitor Permanent Resident Other, please specify:
Is English your native language?
Yes No, please explain:
College Guidelines
Trinity College of Nursing & Health Sciences is asked by the federal government, accrediting associations, college guides, newspapers, and our own college/university communities, to describe the racial/ethnic backgrounds of our students and employees. In order to respond to these requests, we ask you to answer BOTH of the following:
Do you consider yourself to be Hispanic/Latino?
Hispanic / Latino
Not Hispanic / Latino
Ethnic Origin? (Optional)*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander; Tribal/Nation Affiliation:
White
Emergency/Family Contact Information
Parent Spouse Legal Guardian
Other, please specify:
Contact Name (First Last):
First:
Last:
Contact Street Address

Contact City and State
City:
State:
Contact Zip
Contact Phone
555-555-5555

Contact Cell Phone

Contact Work Phone
Please be informed that licensure or certification may be sanctioned for conviction of a crime including a felony, a gross misdemeanor, or misdemeanor with the exception of speeding and parking violations. Additionally, acceptance and successful completion does not guarantee licensure, certification, or employment, which may be contingent on factors unrelated to the education process.
1. Do you have a record of convicted child or dependent adult abuse? Yes No
2. Have you ever been convicted of a crime in this state or any other? Yes No
3. Are you currently incarcerated? Yes No
4. Have you ever been excluded from or served with notice of exclusion from any governmental programs, i.e., medicare, medicaid, financial aid, loan default? Yes No
If yes to any questions, explain and give dates:
Military Service

Are you currently on active duty?
Yes No

United States Veteran?
Yes No

For what branch of military are you a veteran?

Are you receiving veteran's benefits?
Yes No

Education
List below the high school from which you graduated (only) and all colleges and universities you have ever attended. A current, official transcript sent directly from each institution must be on file to fully process your application. Send transcripts to:
Trinity College of Nursing & Health Sciences
2122 25th Avenue
Rock Island, IL 61201-5317
Name of School Address Date of Entrance
MM/YYYY
Date of Leaving
MM/YYYY
Diploma, Degree Recieved or Credits Earned
General Education Diploma (GED)
High School
College
College
College
College
College
Other

All previous educational institutions attended must be listed, regardless if credit was awarded or not.

Have you taken or are you scheduled to take the American College Test (ACT) or the Scholastic Aptitude Test (SAT)?
SAT Yes No
If yes, indicate month and year:
Month Year
ACT Yes No
If yes, indicate month and year:
Month Year
Admission Information
Fill out the application and:
  1. Submit application online with a $50 non-refundable fee.
  2. OR Print a copy and return by mail with a $50 non-refundable fee to Trinity College of Nursing & Health Sciences.
  3. Please select if you are re-applying. There is a $15 non-refundable fee and re-application cannot be processed without payment.
For which session are you applying? (choose one and note year)
Desired Enrollment Status: Part Time Full Time
Desired Date of Enrollment: Fall (August) Spring (January) Summer (May/June)
Year of Enrollment:
Program(s) to which you are applying:
Trinity College of Nursing & Health Sciences - Rock Island, IL
Associate of Science in Nursing (ASN)
LPN to ASN Advanced Placement
Bachelor of Science in Nursing (BSN) Accelerated (2nd degree, 15 months)
BSN - Basic (24 months)
BSN - Completion (RN-BSN)
Associate of Applied Science in Respiratory Care
Associate of Applied Science in Radiography
Radiography Internship - CVI
Radiography Internship - CT
Undeclared
Are you currently: Registered Licensed Certified N/A
Identify type: License Number: Exp Date: State

Is there a restriction on your license/certificate? Yes No

Current Professional Certification Title
Credentialing Organization Renewal Date
Current Employer
Name
Address
Position
Are you planning to apply for financial aid? Yes No
How did you become interested in applying to an Trinity College of Nursing & Health Sciences?
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Admission Representative College Fair Counselor
Currently Enrolled or working at Iowa Health System Affiliate Faculty Friends Family Member
Career Day High School Visit Affiliate Staff Trinity College Website
Mailings Pastor Other, please specify:
Application Payment
I wish to pay the
  • $50 application fee
  • $15 re-application fee
by:
Please charge my
Card Number
Verification Code
Expiration Date
Credit Card Billing Address

City:
State:
Zip
Signature and Submission

Read the Statement Below Before Signing:

Please be informed that licensure or certification may be sanctioned for conviction of a crime including a felony, a gross misdemeanor, or misdemeanor with the exception of speeding and parking violations. Additionally, acceptance and successful completion does not guarantee licensure, certification, or employment, which may be contingent upon factors unrelated to the education process. Trinity College of Nursing & Health Sciences admits students regardless of race, color, religion, sex or sexual orientation, national or ethnic origin, gender, disability, or age in admission, employment, programs, or activities. Persons having inquiries regarding compliance with Title IV, Title IX or Section 504 or any other questions may contact the Admissions Office at Trinity College of Nursing & Health Sciences or the Assistant Secretary for Civil Rights, US Department of Education.

Verification

I certify that the information contained in this application is accurate and complete to the best of my knowledge. I understand that any misrepresentation of the facts as stated or implied on this application is considered sufficient cause for reconsideration of my admission status, including withdrawal.

Iowa Health System does not discriminate on the basis of race, color, religion, national origin, gender, age or qualifying disability in admission, employment, programs, or activities. Persons having inquiries regarding compliance with Title VI, Title IX or Section 504 or any other questions may contact the Admissions Office at an Iowa Health System College or the Assistant Secretary for Civil Rights, US Department of Education.

Trinity College of Nursing & Health Sciences
Student Services
2122 25th Avenue
Rock Island, IL 61201
con@trinityqc.com
(309) 779-7700
Fax: (309) 779-7796
http://www.trinitycollegeqc.edu/

I certify that to the best of my knowledge, the information provided in this application is complete and true. I understand that falsification or omission of information is sufficient cause for denial of my application or dismissal from the Iowa Health System Colleges.

CLINICAL PERFORMANCE STANDARDS

To successfully perform clinical functions while enrolled at Trinity, applicants/students must have sufficient physical strength, coordination, manual dexterity, and mental and sensory processes to be capable of providing safe and effective client care including but not limited to the following situations:

  • Handling stressful or demanding situations related to mechanical, technical, procedural, or client care situations.
  • Communicating effectively in order to explain and provide client /family care.
  • Providing physical and emotional support to clients/families.
  • Physically responding to situations requiring first aid or emergency care of clients.
  • Sensorial assessing and evaluating clients conditions/diagnostic tests.
  • Transporting, moving, lifting or transferring clients as is necessary to provide client care.
  • Moving, adjusting and manipulating a variety of equipment according to established procedures and standards.
  • Physically placing clients, equipment, and instruments in proper positions for examinations according to established procedures and standards.

If the ability to meet any of these clinical performance standards is in question, Trinity College of Nursing & Health Sciences reserves the right at any point in the application process/program to require a simulated clinical test to verify an applicant/ studentâ??s capabilities. If the applicant/learner cannot meet these clinical performance standards without accommodation, a conference shall be held between applicant/student and the respective Department Director to determine what accommodations would be necessary and if the accommodation is reasonable.

My signature indicates, that I can comply with the clinical performance standards and understand that, if with reasonable accommodation, I cannot meet these Clinical Performance Standards, I may be withdrawn at any point in the application process/ program.




Applicant/Electronic Signature
Type in your name


Date
Type in the Date (mm/dd/yyyy)