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APPLICATION FORM FOR ADMISSION TO
PARKLAND SCHOOL OF NURSE-MIDWIFERY 2003-2004
To the Applicant:
If sufficient space is not available on the form, please note and attach additional
pages as necessary.
Please attach explanatory notes if you feel they are needed.
NAME 1
________________________________________________________________________________________
Last First Middle
PERMANENT MAILING ADDRESS
Home Telephone ( ) Office Telephone ( )
Applying for Full Time Option ______ Part Time Option ______ Either _______
EDUCATIONAL BACKGROUND
Please list chronologically all the schools of nursing, colleges/universities you
have attended or are currently attending. Official transcripts from all programs are
required. Transcript requests are found elsewhere within the application packet. If
additional space is needed, please photocopy form and attach. Please remember a
Bachelor's degree is required although it does not need to be in nursing.
NURSING/COLLEGE/UNIVERSITY DEGREE AND DATE2 MAJOR MINOR
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
1 Your application will be filed
under this surname. Please be certain all credentials and correspondence use
this full name.
2 Includes Degrees granted or expected
to be granted.
CURRENT R.N. LICENSURE STATE_____________________ NUMBER_____________________ EXP. DATE_______________
PROFESSIONAL EXPERIENCE Please list chronologically your professional
experiences. Briefly describe
your responsibilities in the position held and reasons for leaving. Photocopy
and use additional paper if needed.
Employer Location Dates Position & Description
ACADEMIC HONORS, PRIZES, SCHOLARSHIPS, MEMBERSHIP IN PROFESSIONAL
ORGANIZATIONS.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
FOREIGN LANGUAGE(S) __________________ LEVEL OF PROFICIENCY _____
ADVANCED PHYSICAL ASSESSMENT COURSE (Graduate Level)
COLLEGE/UNIVERSITY _______________________________DATE __________________
LENGTH OF COURSE __________________________________
Advanced Physical Assessment Course must be successfully completed within the
last five years or currently
enrolled by the time of interviews.
PUBLICATIONS, RESEARCH, PRESENTATIONS:
____________________________________________________________________________________
____________________________________________________________________________________
CERTIFICATION If you currently possess certification, please identify awarding
agency, date and type
of certification. ________________________________________________________________________
______________________________________________________________________________
CONTINUING EDUCATION ATTENDED IN LAST TWO YEARS: ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
CHILDBIRTH EDUCATION
Have you taught childbirth education classes within the last 5 years? YES NO
Are you a certified instructor? YES NO If yes, by whom are you certified?
FETAL MONITORING REQUIRED REFERENCES Please list the names of the individuals
of whom you are
requesting a letter of reference. Suggested sources include a supervisor (preferably
of your current
position), an instructor from an academic program that you attended and a professional
colleague.
Forms for the letters are found elsewhere in the application packet.
NAME TITLE ADDRESS
1. __________________________________________________________________________
2. __________________________________________________________________________
3. __________________________________________________________________________
FINANCIAL STATUS Recognizing that substantial employment opportunities are limited
during a nurse-midwifery
program, how do you plan to finance your education? ____________________________________________________________________________________
____________________________________________________________________________________
ESSAYS As part of the application form, you must answer all four of the following
essay questions. Please use
separate sheets for each question and all essays should be typed, double spaced
and no more than 500 words
for any question.
QUESTION 1 What do you understand to be the responsibilities of a Certified
Nurse-Midwife?
QUESTION 2 How do you perceive a nurse-midwife's preparation and practice as
different from a very
competent: A. Labor/delivery/postpartum nurse B. Obstetrical/gynecologic nurse
practitioner C. Lay midwife
QUESTION 3 Why are you personally interested in becoming a nurse-midwife? (Please
include any
reasons why you feel that you should be given priority in the student selection
process).
QUESTION 4 What are your professional aspirations upon certification as a nurse-midwife?
(Please include a
description of your anticipated/desired practice site and population).
OPTIONAL INFORMATION Under Title VI of the Civil Rights Act of 1964, your cooperation
in answering the
following questions is strictly voluntary, but would be appreciated.How would
youdescribe yourself?
Choose only one.
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African-American _____ |
Native American (American Indian) _____ |
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Caucasian _____ |
Cuban-American _____ |
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Mexican-American _____ |
Oriental/Asian-American _____ |
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Puerto Rican _____ |
Other Spanish _____ |
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Other _____ |
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OTHER INFORMATION How did you learn about this program? ______________________________________________________________________________ ______________________________________________________________________________ Have you ever applied to another Nurse-Midwifery Education Program? YES _____ NO _____ How Many _____ If yes, what is the status of the application(s)? Admitted ____________________ Denied _________________________ Wait List ___________________ Pending ________________________ I hereby certify that the information provided by me is true, complete and accurate.I understand that all credentials submitted in support of this application become the property of Parkland School of Nurse-Midwifery and are not refundable. Signature _____________________________________ Date _____________________ Application fee is $50.00 (non-refundable). Make check or money order payable to Parkland School of Nurse-Midwifery and attach to Application Form. All forms should be sent to: Admissions Committee Parkland School of Nurse-Midwifery 5201 Harry Hines Blvd. Mail Station 6017-A Dallas, TX 75235 (214) 590-2580 All applications are due by April 7, 2003 Note:Parkland School of Nurse-Midwifery admits qualified students of any age, sex, race, color, national and ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the school. ****************************************************************************** WAIVER FOR INFORMATION We intend to honor an individual's confidentiality. One way in which we do so is by not releasing information about your application status over the phone since we are unable to verify identification. Should you wish to be able to call and receive such information, please sign the waiver below. When you call, you will be asked to identify yourself by your Social Security number. Your Social Security number will only be used for this purpose, and with your permission given below. I hereby authorize Parkland School of Nurse-Midwifery to release information about my application status to myself/individuals who identify appropriate authorization by requesting such information and producing the following Social Security number: _______________________________________ SOCIAL SECURITY NUMBER _______________________________________ NAME _______________________________________ SIGNATURE _______________________________________ DATE ****************************************************************************** LETTER OF REFERENCE To the APPLICANT: Please complete the demographic information required at the top of this form and send it to the person you have identified. I hereby waive my right of access to this reference letter and understand that I will not be able to see it under any circumstances ______________________________________________ Signature I DO NOT waive my right of access to this reference letter ______________________________________________ Signature NAME _____________________________ SOCIAL SECURITY NUMBER ________________ IF APPLICABLE, OTHER NAMES KNOWN BY ______________________________________ To the individual from whom the reference is requested. The above individual has applied for application the Parkland School of Nurse-Midwifery. We value your appraisal of his/her abilities and potential, either in response to the questions on this form or in a separate letter. We must receive this letter prior to April 7, 2003 for consideration of applicant. How long and in what capacity have you known the applicant? ______________________________________________________________________________ ______________________________________________________________________________ If you have known the applicant in an academic setting, please use the rating scale below to compare the applicant to other students in his/her graduating class. If you have known the applicant in a professional setting, please use the rating scale below to compare the applicant to other nurses in the same or similar settings.
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Clinical Effectiveness |
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Leadership |
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OTHER COMMENTS: Do you believe this applicant is qualified for: _______ Any nurse-midwifery program _______All nurse-midwifery programs except the most physically or academically demanding (circle one/both) _______Only moderately demanding programs, either physically or academically (circle one/both) Signed _________________________________ Date ________________________________ Name ________________________________ Title _______________________________ Address ________________________________ Phone ( ) ****************************************************************************** Prompt consideration of this form will be appreciated by both the candidate and the school, for the application cannot be acted upon until your recommendation is received. All recommendations must be received by April 7, 2003. Please mail your reply to: Admissions Committee, Parkland School of Nurse-Midwifery 5201 Harry Hines Blvd., Mail Station 6017-A, Dallas, Texas 75235, (214) 590-2580 REQUESTS FOR TRANSCRIPTS To the APPLICANT. To assist you in obtaining the needed transcripts, you will find transcript requests which may be cut and sent to the appropriate institution. Please enter your name and requested information in the spaces provided below and mail it directly to the school you attended. BE CERTAIN THAT YOU SIGN THE AUTHORIZATION FOR RELEASE. You are responsible for any fees for this service assessed by the institution in question. ***********************************DETACH HERE*************************************** To the Registrar or Appropriate Official: The individual named below is filing an application at Parkland School of Nurse-Midwifery. We would appreciate you sending ONE (1) OFFICIAL TRANSCRIPT of his/her performance at your institution. All application materials are due on or before April 7, 2003. Please send the transcript to: Admissions Committee, Parkland School of Nurse-Midwifery, 5201 Harry Hines Blvd. Mail Station 6017-A, Dallas, Texas 75235 COLLEGE/UNIVERSITY __________________________________________________________ ADDRESS OF COLLEGE/UNIVERSITY _____________________________________________ _____________________________________________ _____________________________________________ NAME ________________________________________________________________________ OTHER NAMES UNDER WHICH RECORDS MAY BE LISTED________________________________ YEARS(S) OF ATTENDANCE __________ SSN#_________________________ AUTHORIZATION FOR RELEASE ___________________________________________________ ***********************************DETACH HERE*************************************** To the Registrar or Appropriate Official: The individual named below is filing an application at Parkland School of Nurse-Midwifery. We would appreciate you sending ONE (1) OFFICIAL TRANSCRIPT of his/her performance at your institution. All application materials are due on or before April 7, 2003. Please send the transcript to: Admissions Committee, Parkland School of Nurse-Midwifery, 5201 Harry Hines Blvd. Mail Station 6017-A, Dallas, Texas 75235 COLLEGE/UNIVERSITY __________________________________________________________ ADDRESS OF COLLEGE/UNIVERSITY _____________________________________________ _____________________________________________ _____________________________________________ NAME ________________________________________________________________________ OTHER NAMES UNDER WHICH RECORDS MAY BE LISTED________________________________ YEARS(S) OF ATTENDANCE __________ SSN#_______________________________________ AUTHORIZATION FOR RELEASE ___________________________________________________ ***********************************DETACH HERE*************************************** To the Registrar or Appropriate Official: The individual named below is filing an application at Parkland School of Nurse-Midwifery. We would appreciate you sending ONE (1) OFFICIAL TRANSCRIPT of his/her performance at your institution. All application materials are due on or before April 7, 2003. Please send the transcript to: Admissions Committee, Parkland School of Nurse-Midwifery, 5201 Harry Hines Blvd. Mail Station 6017-A, Dallas, Texas 75235 COLLEGE/UNIVERSITY __________________________________________________________ ADDRESS OF COLLEGE/UNIVERSITY _____________________________________________ _____________________________________________ _____________________________________________ NAME ________________________________________________________________________ OTHER NAMES UNDER WHICH RECORDS MAY BE LISTED_________________________ YEARS(S) OF ATTENDANCE __________ SSN#_________________________ AUTHORIZATION FOR RELEASE ___________________________________________________
PHYSICAL EXAMINATION NAME _______________________________________________________________________________ ADDRESS ____________________________________________________________________________ HISTORY: AGE_________ If appropriate, GRAVIDA___________ PARITY____________________________ PAST MEDICAL HISTORY: ILLNESSES ____________________________________________________________________ ALLERGIES ____________________________________________________________________ RUBELLA STATUS _____________(Date) HEPATITIS STATUS ___________(Date) SURGERY/HOSPITALIZATIONS _____________________________________________________ CURRENT MEDICATIONS __________________________________________________________ REVIEW OF SYSTEMS __________________________________________________________________ FAMILY HISTORY _____________________________________________________________________ SOCIAL HISTORY SMOKING _______________________________________________________________________ ALCOHOL _______________________________________________________________________ DRUGS _________________________________________________________________________ PHYSICAL EXAMINATION BP __________ PULSE __________ WT __________ HT __________ GENERAL _______________________________________________________________________ HEENT _________________________________________________________________________ NECK __________________________________________________________________________ BREASTS _______________________________________________________________________ LUNGS _________________________________________________________________________ HEART _________________________________________________________________________ ABDOMEN _______________________________________________________________________ BACK __________________________________________________________________________ PELVIC (If appropriate) _______________________________________________________ EXTREM ________________________________________________________________________ NEURO _________________________________________________________________________ LAB ___________________________________________________________________________ IMPRESSION ____________________________________________________________________ PLAN __________________________________________________________________________ This individual is an applicant for the Parkland School of Nurse-Midwifery. Do you in your professional judgment, feel he/she is able to participate fully in the academic and clinical program: Without any limitations _______________ With limitations (Specify/attach additional page, if necessary) ___________________________________________________________________________________ SIGNATURE OF EXAMINER _____________________________________________ DATE ________________ NAME OF EXAMINER ________________________________________________________________________ ADDRESS _________________________________________________________________________________ CNM_____ MD_____ NP______ OTHER(Specify)________________________
To the APPLICANT. Before you mail your forms back to the Parkland School of Nurse- Midwifery, spend a few minutes with this check list and verify that you have completed all necessary forms and activities. Are you familiar with the deadline? (All materials must be received at Parkland School of Nurse-Midwifery by April 7, 2003) Do you meet the criteria, including the Physical Assessment course requirement? Have you requested all your letters of references to be sent directly to Parkland School of Nurse-Midwifery? (See Letter of Reference forms) Have you taken a physical assessment course within the last five years? Was it on the graduate (not undergraduate) level? Have you requested all transcripts to be sent directly to Parkland School of Nurse-Midwifery? (See requests for transcripts) Remember that if you do not have a 3.0 GPA cumulative, you must have a GRE score submitted of 1,000 verbal and quantitative combined. We will accept the letter sent to you verifying your GRE score. Do you wish to obtain telephone information regarding your application status? (See Waiver of Information form) Have you completed all aspects of the application form? Have you enclosed the $50.00 non-refundable fee for the application process? When you answer yes to all of the above questions, mail your application form, physical examination form, and waiver of information form (if appropriate) to: Admissions Committee Parkland School of Nurse-Midwifery 5201 Harry Hines Blvd. Mail Station 6017-A Dallas, TX 75235
References and Transcripts are to be sent directly to the same address.
If you have any questions about the above process, please call the Parkland
School of Nurse-Midwifery at
(214) 590-2580
Send Email to: Webmaster@parknet.pmh.org