Norma N Gill Center for WOC Nursing Education

Admissions Application WOC Nursing Education

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Cleveland Clinic does not discriminate in admission, employment, or administration of its programs or activities, on the basis of age, gender, race, national origin, religion, creed, color, marital status, physical or mental disability, pregnancy, sexual orientation, gender identity or expression, genetic information, ethnicity, ancestry, veteran status, or any other characteristic protected by federal, state or local law. In addition, Cleveland Clinic administers all programs and services without regard to disability, and provides reasonable accommodations for otherwise qualified disabled individuals.

PERSONAL DEMOGRAPHIC DATA*

		enter here
Name
Address
City, State, Zip code
Home phone
Other phone
email address
Last 4 digits of Social Security number
Date of Birth

2.	Please list all names that may appear on your official college transcripts (i.e. maiden name).

Place of Employment*

		enter here
Name of organization
Address of organization
Phone
Fax
Supervisor
Supervisor phone
email

Are you interested in an online or onsite course?*

	Online
	Onsite

When would you like to attend class?*

	Winter
	Spring
	Fall

Year? Please specify

6.	Please copy and paste your resume (CV) into this text box. * Include education background, work experience, and professional organization and community involvement. Include any offices and committee appointments held.

7.	In 300-500 words, please tell us about yourself, your career goals, & reason for applying to our program.*

PHYSICAL PERFORMANCE:

The role and function of the WOC nursing student involves being able to handle & lift patients, manual & finger dexterity, eye/hand coordination, standing & walking for extensive periods of time, lifting & carrying items weighing up to 50 pounds, and hearing & vision corrected to normal range. If you require assistance or assistive devices in meeting these requirements, please notify the Program Director at WOCschool@ccf.org at the time of your application.*

Yes, I meet the physical requirements

Other, please specify

The minimum requirements for admission to this WOC Nursing Education Program include Registered Nurse with a bachelor's degree (or higher), & one year experience as an RN.*

I meet this criteria

Other, please specify

10.

Are you authorized to work or study in the United States? International students must demonstrate English language proficiency by taking the Test of English as Foreign Language (TOEFL), and achieve a minimum score of 60 on the internet based test or 500 on the paper based test. The TOEFL test measures ability to use and understand the English language as it is spoken in a classroom setting. The test, given in four sections, measures how well you read, listen, speak and write in English as well as using these skills together. If you are an international student, please go to TOEFL website at www.toefl.org to complete this test then fax the results to our office at 216-445-6343 or forward to WOCschool@ccf.org*

I am authorized to work or study in the United States

Other, please specify

11.

Please indicate who should be invoiced for the tuition payment:*

	Self pay
	Employer
	Shared

Other, please specify

12.

How did you hear about our WOC nursing education program?*

	WOCN website
	WOCN journal
	WOC Nurse
	Vendor Representative
	Advertisement

Other, please specify

13.

I understand that any misrepresentation or omission of facts called for on this application is cause for cancellation of the application or expulsion from the program.*

I agree

14.	By typing my name here I hereby certify that the information in this admissions application is, to the best of my knowledge, correct.*