Kentucky BSN Application

Please fill out the following application for the Kentucky BSN program.

    

Your Information
 
First Name    Middle Name    Last Name    Suffix
     
E-mail

Maiden Name (if applicable)
Preferred Name
 
Date of Birth (MM-DD-YYYY)
Social Security Number
 
Gender
 
 
 
MAILING ADDRESS
 
Street Address
Address Line 2
 
City
State / Province / Region
 
Postal / Zip Code
Country
 
County
 
 
Home Phone Number (with Area Code)
 
 
Cell Phone Number (with Area Code)
 
 
Work Phone Number (with Area Code)
 
 
Extension (if applicable)
 
 
Shift worked?
 
 
Emergency Contacts
 
Primary Contact
 
Last Name
First Name
 
Relation
If "Other", please specify:
 
Street Address
Address Line 2
 
City
State
 
County
Postal / Zip Code
 
Home Phone Number
Cell Phone Number
 
Preferred Email
 
 
Secondary Contact (Optional)
 
Last Name
First Name
 
Relation
If "Other", please specify:
 
Street Address
Address Line 2
 
City
State
 
County
Postal / Zip Code
 
Home Phone Number
Cell Phone Number
 
Preferred Email
 
 
Have you ever been convicted of a felony:
 
 
If Yes, please explain.
 
Do you consent to a criminal history check?
 
 
 

 
Date of high school grad. or completion of GED:
 
Please specify high school diploma or GED
 
 
Month and year you plan to enroll (MM-YYYY):
 
 
 
 
 
Example:
 
 
 
Are you currently a registered nurse?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do you plan to attend full-time or part-time?
 
 
Have you attended McKendree University before?
 
If yes, provide the last date attended (MM-YYYY)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Have you visited campus?
 
 
If you chose yes above, please specify (MM-YYYY)
 
 
 
 
 
Example:
 
 
 

 
Are you a veteran?
 
 
Are you a United States citizen?
 
If you chose no, please describe your status
 
 
 
Are you Hispanic or Latino?
 
 
 
American Indian or Alaska Native
 
Asian
 
Black or African American
 
Native Hawaiian or Other Pacific Islander
 
White
 
American Indian or Alaska Native
 
Asian
 
Black or African American
 
Native Hawaiian or Other Pacific Islander
 
White
 
Religious Background/Denomination
 
 
APPLICANT'S AFFIDAVIT
 
Date (MM-DD-YYYY)
Initials