Form test First Name (legal name) *Last Name (legal name) *CSU School ID # *Is this your ____ application for admission to the College of Nursing? *1st2nd3rdTerm *Please select an optionFallSpringTerm Applying ForYear *Please select an option202320242025Term Applying ForSection 1: Personal RecordDate of Birth *Permanent Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweEmail AddressBucMail Address *Phone Number *Social Security Number/VISA Number *Spouse/Parent/Guardian *Please select an optionSpouseParentGuardianNot ApplicableNamePhoneEmail AddressStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweAre you an International Student? *YesNoCountry of Origin/CitizenshipSection 2: Academic RecordI am currently registered as a student at CSU. *YesNoI am currently enrolled or have previously completed NURS104 at CSU. *YesNoDo you have a professional license? *I am currently enrolled in another college/university. *YesNoName and location of college/universityI have been enrolled in a nursing program at another college within the last five years. *YesNoIf yes, what was your reason for leaving the program?0 / 200I am applying for early acceptance. *YesNoEligibility Requirements for Early AcceptanceClick here for more information.Explain your current statusPrevious College/University/Professional Nursing SchoolName of School *City/State *Dates Attended *Diploma Conferred *Name of School *City/State *Dates Attended *Diploma Conferred *I am eligible to return in good standing to any postsecondary institution and nursing program I have attended *YesNoIf no, please explain *Section 3: Employment HistoryCurrent place of employmentCurrent employer and phone numberCurrent job description at place of employmentPrevious place of employmentPrevious employer and phone numberPrevious job description at place of employmentSection 4: Healthcare Employment HistoryCurrent healthcare employmentCurrent healthcare employer and phone numberCurrent job description at place of healthcare employmentPrevious healthcare employmentPrevious healthcare employer and phone numberPrevious job description at place of healthcare employmentPlanning Sheet The following courses are the pre-nursing prerequisites required for a Bachelor of Science in Nursing degree at Charleston Southern University and must be completed or currently enrolled prior to applying. English 111 and 112 (3 credits each) Math 105 or higher (3 credits) Chemistry 110 or higher (4 credits) Biology 226 & 227; Human Anatomy and Physiology w. Lab I and II (4 credits each) Biology 220; Microbiology w. Lab (4 credits) Psychology (3 credits) Nursing 104 (3 credits) Liberal Arts Class (3 credits) All math and science prerequisites must be completed within 5 years at time of application. Must have a GPA of 2.9 or better in all prerequisite courses with a “C” or higher. For transfer students only - Official transcripts from all previous schools must be on file with the CSU Registrar by 5:00 p.m. on the Tuesday following Charleston Southern University’s finals week.*Please print an unofficial transcript from MyCSU and submit to the College of Nursing advising office (if you are unable to print from MyCSU, contact your pre-nursing advisor) Demographic InformationPlease respond to each area. The College of Nursing responds to numerous surveys from professional, community and church organizations and the information you provide will assist us in providing accurate data to them. The information on this form is not used for admission decisions. See CSU Undergraduate Catalog for FERPA Notice of Directory Information Policy. Gender *MaleFemaleMarital Status *MarriedSingleSeparated/DivorcedWidowedDo you have an associate degree? *YesNoSpecify majorDo you have a baccalaureate or higher degree? *YesNoSpecify degree and majorDo you have plans or aspirations for further education following completion of a Bachelor of Science in Nursing? *YesNoWhat are your plans?Ethnic Background *American Indian/Alaskan NativeAsian or Pacific IslanderHispanic originBlack, not of Hispanic originWhite, not of Hispanic originIf you have a Healthcare and/or Military background, please explain in detail:LPN or CNAIf you are currently licensed as an LPN or CNA, please indicate your license number and the state in which you are licensed. Are you a licensed LPN or CNA? Choose one, if so.LPNCNALicense NumberSignature If accepted into the College of Nursing, students will be required to provide evidence of the following, prior to the first semester in the nursing program: Level of health and ability necessary to perform essential functions of nursing care. Reasonable accommodations will be made for some disabilities. However, independent performance is expected in several areas including: observation skills, ability to communicate, ability to deliver physical care and perform technical procedures and ability to function in quickly changing environments and stressful situations. Health Forms will be forwarded for completion by a health care provider. Completion of all required immunizations and titers (delineated on Health Form) including Hepatitis B Completion of a TB test within 3 months prior to enrollment in nursing courses Current CPR certification from the American Heart Association (BLS, Health Care Provider) Personal Health insurance (Medishare programs do not qualify) Professional liability insurance (information will be forwarded) Criminal Background Check Negative Drug Screen I have read and understand the information on this form. Fact sheets describing the documentation needed to be eligible for licensure as a registered nurse are available upon request in the College of Nursing. If there are questions as to the anticipated need to report a specific violation/conviction, disciplinary action, treatment for chemical dependency, or a psychiatric or mental health condition, students may call the South Carolina Board of Nursing at (803) 896-4550. I certify that I have read the information contained in this application, understand the requirements and attest that all information provided by me is true and correct to the best of my knowledge. I understand that my falsification of an application is cause for disqualification or dismissal. Digital Signature *Date * SubmitPlease do not fill in this field.