LPN to RN Application for Admission

Please complete the following application for the LPN to RN Associate of Science program.

Make sure you have applied and been accepted to Louisiana Delta Community College BEFORE completing this application. You must also be advised by an ASN faculty member before completing this application.

Name Name First Middle Last
All other names used:
Birthday Birthday / MM / DD YYYY
LoLA ID
Social Security Number
Must be 9 digits. Currently Entered: 0 digits.
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
LDCC Email Address
Home phone number Home phone number - ### - ### ####
Work phone number Work phone number - ### - ### ####
Primary cell phone number Primary cell phone number - ### - ### ####
Alternative cell phone number Alternative cell phone number - ### - ### ####
Alternative person to contact Alternative person to contact First Last
Alternative person to contact's phone number Alternative person to contact's phone number - ### - ### ####
Are you currently working as an LPN?

Are you currently working as an LPN? Yes No
Years of experience?
Working Acute Care?

Working Acute Care? Yes No
Years of experience?
Working long-term Care?

Working long-term Care? Yes No
Years of experience?
Working other setting?

Working other setting? Yes No
Describe other setting if applicable:
Years of experience?
LPN License Number:
LPN License Expiration Date: LPN License Expiration Date: / MM / DD YYYY
Current employer name:
Employer's Address Employer's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Other Certification(s) and their Expiration(s):
Year of PN graduation:
Supervisor
PN Institution
PN Institution's phone number: PN Institution's phone number: - ### - ### ####
City and State of PN Institution (city, state)
Will you be able to provide a hard copy of your official PN Transcript, with school seal, if you are a non-LDCC graduate? (If you answer no, the application is considered incomplete.)

Will you be able to provide a hard copy of your official PN Transcript, with school seal, if you are a non-LDCC graduate? (If you answer no, the application is considered incomplete.) Yes No
Will you be able to provide a letter of recommendation from past or current healthcare employer or instructor? (If you answer no, the application is considered incomplete.)

Will you be able to provide a letter of recommendation from past or current healthcare employer or instructor? (If you answer no, the application is considered incomplete.) Yes No
Please fill in your TEAS test date(s) and score(s) below.
Indicate age range:

Indicate age range: 17-20 21-25 26-30 31-40 41-50 51-60 61 and older
Classification by credit hours:

Classification by credit hours: Freshman (<30 hours) Sophomore (at least 30 hours) Junior (at least 60 hours) Senior (at least 90 hours)
Gender:

Gender: Female Male Prefer not to say
Ethnicity

Ethnicity Hispanic Asian Black/African American White/Caucasian American Indian or Alaskan Native Hawaiian or Other Pacific Islander Other
If admitted to the program, I will also be taking non-nursing courses:

If admitted to the program, I will also be taking non-nursing courses: Yes No
Special Populations

Special Populations Disability Economically disadvantaged Single parent Displaced homemaker Migrant status Nontraditional
Is English my second language?

Is English my second language? Yes No
TOEFL iBT: Overall Score
TOEFL iBT: Speaking Score
Please select which campus LPN-RN program you are applying for:
Unofficial Transcripts:

Attach Files
Curriculum plan:

Attach Files
Copy of degree(s) received:

Attach Files
Test scores for TOEFL iBT:

Attach Files
Letter of recommendation from CURRENT healthcare place of employment:

Attach Files
Proof of one year experience as an LPN:

Attach Files
Recommendation form:

Attach Files
Copy of official verification from the Louisiana State Board of Practical Nurse Examiners (LSBPNE) of an unencumbered LA practical nurse license:

Attach Files