Application for RN to BSN

**Please double check your application for accuracy before submitting.

    

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

Maiden Name (if applicable)
Preferred Name
 
Date of Birth (MM/DD/YYYY)
Gender
 
Social Security Number
 
 
 
 
McKendree University
 
McKendree Online
 
701 College Road
 
Lebanon, IL 62254
 
Address
 
Street Address
Address Line 2
 
City
State / Province / Region
 
Postal / Zip Code
Country
 
Home Phone (with Area Code)
Cell Phone (with Area Code)
 
Work Phone (with area code)
Work Extension (if applicable)
 
Preferred Contact
 
 
 
 
 
Indicate month/year you plan to enroll in college
Location
 
Are you a BJC or SIH Healthcare employee?
 
 

 
EDUCATIONAL BACKGROUND
 
Name of High School
 
Date of High School Graduation
or Date GED Obtained
 
 
Please follow this template:
 
 
ADN or Diploma program completed
Year of ADN graduation
 
Are you currently a registered nurse?
 
 
If no, are you or will you be board eligible?
 
 
If yes, date of board eligibility (MM-DD-YYYY)
 
 
 
 
Do you plan to attend
 
 
 
 
 
 
 
 
 
Please upload in a Word document.
 
 
 
 
 

 
ADDITIONAL INFORMATION
 
 
 
 
Are you a Veteran?
 
 
Are you a U.S. Citizen?
 
 
If no, describe your status below
 
 
 
 
Are you Hispanic or Latino?
 
 
 
What is your race? (Check all that apply)
 
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
 
 
Have you ever had a felony conviction?
 
 
If yes, please explain
 
Do you consent to a criminal history check?
 
 
 

 
SUPPLEMENTAL INFORMATION
 
 
 
Who is your current employer?
 
 
What shift do you typically work?
 
Have you taken an online class for college credit?
 

 
APPLICANT'S AFFIDAVIT
 
 
Date (MM/DD/YYYY)
Initials