Nursing Application for Traditional Admission

Please complete this form to apply for traditional admission for the Associate of Science in Nursing 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
LDCC ID
All other names used:
Birthdate Birthdate / MM / DD YYYY
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 Cellphone Number Primary Cellphone Number - ### - ### ####
Alternative person to contact's name Alternative person to contact's name First Last
Alternative person to contact's phone number Alternative person to contact's phone number - ### - ### ####
Social Security Number
Must be 9 digits. Currently Entered: 0 digits.
Education and Experience
Do you currently have another degree?

Do you currently have another degree? Yes No
If you answered yes to the previous question, please describe your degree below.
Are you an LPN?

Are you an LPN? Yes No
Do you have another healthcare discipline?

Do you have another healthcare discipline? Yes No
If you answered yes to the previous question, please describe which discipline you currently possess:
Have you previously applied to this or another nursing program?

Have you previously applied to this or another nursing program? Yes No
Have you previously applied to this or another nursing program more than one time?

Have you previously applied to this or another nursing program more than one time? Yes No
First school you applied to:
Is the school above in Louisiana?

Is the school above in Louisiana? Yes No
Were you accepted and enrolled in clinical courses at the first school you applied to?

Were you accepted and enrolled in clinical courses at the first school you applied to? Yes No
Please provide the dates from which you were enrolled in clinical courses at the first school you applied to.
If the first school you attended was a Louisiana institution, please provide your LSBN student # below.
Second school you applied to:
Is the school above in Louisiana?

Is the school above in Louisiana? Yes No
Were you accepted and enrolled in clinical courses at the second school you applied to?

Were you accepted and enrolled in clinical courses at the second school you applied to? Yes No
Please provide the dates from which you were enrolled in clinical courses at the second school you applied to.
Have you applied to more than two other nursing programs?

Have you applied to more than two other nursing programs? Yes No
Please describe.
If you answered yes to the previous multiple choice question, please explain reasons for non-completion.
Please fill in your TEAS test date(s) and score(s) below.
Are you employed other than healthcare?

Are you employed other than healthcare? Yes No
Please describe your non-healthcare employment and your hours per week:
Miscellaneous
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) Sophomore (at least 30 hours) Junior (at least 60 hours) Senior (at least 90 hours)
Gender:

Gender: Female Male
Special Populations

Special Populations Disability Economically disadvantaged Single parent Displaced homemaker Limited english Migrant status Nontraditional (Male)
If admitted to the program, I will also be taking non-nursing courses at the same time.

If admitted to the program, I will also be taking non-nursing courses at the same time. Yes No
Ethnicity:

Ethnicity: American Indian or Alaskan Native Native Hawaiian or Pacific Islander Black/African American White/Caucasian Hispanic Asian Other
Is English your second language?

Is English your second language? Yes No
Test scores for TOEFL iBT: This document is REQUIRED if you answered "yes" to the above question.

Attach Files
TOEFL iBT Overall Score
TOEFL iBT Speaking Score
Required File Uploads
Unofficial Transcripts:

Attach Files
Curriculum plan:

Attach Files
Copy of degree(s) received (if appplicable):

Attach Files

Nursing Application for Traditional Admission

Nursing Application for Traditional Admission

Education and Experience

Miscellaneous

Required File Uploads