Apply Online – Division of Nursing

You will also need to fill out a general application form as well. If you have not done that yet, you may do so by Clicking Here.

Apply Online - Division of Nursing

Application For:*
- Associate RN Program
- LPN to ASN
Name*
First Last
Middle Name
Former or Prior Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*

Please provide us with the email address you use most often.
Date of Birth*
MM
DD
YYYY

mm/dd/yyyy
Phone*
Please provide your regular, daytime phone number.
Cell Phone
Please provide your personal cell phone number (if it is different from the phone number above). Leave this blank if it's the same number.
Gender*
- Female
- Male
Marital Status*
- Single
- Married
- Divorced
- Widowed
- Separated
County of Residence*
Residency*
- U.S. Citzen
- Non-US citizen (Student Visa)
- Permanent Resident (Green Card)
- Non-US citizen
(This is used for government reporting purposes only. No admissions decisions are based on this.)
Veteran Status*
- No- Not a U.S. Military Veteran
- Yes - U.S. Military Veteran
Country of Birth*
(This is used for government reporting purposes only. No admissions decisions are based on this.)
Social Security Number
Social Security Number (Submitting your Social Security Number (SSN) is not required, and your SSN will not be used to create a student identification number, but it is required to receive certain federal tax benefits. Your SSN is also sometimes helpful to accurately match some records like SAT or ACT test scores.)
Have you ever been arrested? Please answer "No" if No. If yes, please type "yes" and a brief explanation.*
High School*
(Currently attending or the last one you attended; enter GED if appropriate)
Date of High School Graduation*
MM
DD
YYYY

mm/dd/yyyy
Address of High School Last Attended
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Educational Background
List the full name of all colleges, universities, technical schools, military training facilities, or other institutions you are currently or have attended (other than high school). List the most recent school first. (Note: Federal financial aid rules require a complete list. Failure to indicate every institution attended may result in denial of admission.)
Institution*
If you have not attended any other other institutions enter "None"
Date Attended From
MM
DD
YYYY
Date Attended To
Date Format: MM slash DD slash YYYY
Institution #2
Date Attended From
MM
DD
YYYY
Date Attended To
MM
DD
YYYY
List any other degrees that you may have, licenses (CNA, QMA, etc.), or certifications (Medical Assistant); enter "None" if appropriate.*
Professional Experience
Beginning with your present position, list all of your professional employment experiences related to your field of study.
Employer Name*
Enter "None" if appropriate.
Employer Phone
Employer Email
Employer Contact Information
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date Start
MM
DD
YYYY
Date End
MM
DD
YYYY
Employer Name #2
Employer Phone
Employer Email
Employer Contact Information
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date Start
MM
DD
YYYY
Date End
MM
DD
YYYY
Employer Name #3
Employer Phone
Employer Email
Employer Contact Information
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date Start
MM
DD
YYYY
Date End
MM
DD
YYYY
Emergency Contact*
First Last
Emergency Contact Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Phone*
Relationship to Emergency Contact*
Is there any medical condition of which you would like the College to be aware of? If so, please identify below:
Accuracy Statement
Admission to Ancilla College Nursing program may be granted only after general admission to Ancilla College has transpired and all admission standards are met. I authorize Ancilla College to make appropriate inquires, when necessary, to verify the accuracy of any information provided. I understand that drug and alcohol testing is mandatory while attending the RN or LPN to RN Bridge program. All of this information may impact my admission status or ability to continue in any program above. I certify that the statements submitted in this application are correct to the best of my knowledge. I understand failure to answer questions on the form truthfully and accurately might make me ineligible for admission to Ancilla College or may result in my dismissal from the College and/or the nursing program.
E-Signature Name*
First Last
Comments
This field is for validation purposes and should be left unchanged.

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Ancilla College is a liberal arts institution of higher learning sponsored by the Poor Handmaids of Jesus Christ and is part of The Center at Donaldson. The college’s religious tradition is Roman Catholic; its climate, ecumenical. In a caring environment, Ancilla serves a diverse population, as we transform and empower students to achieve high academic goals, lifelong learning, successful careers and values-centered lives.

ABOUT ANCILLA

Ancilla College, founded in 1937, is a private, Catholic, not-for-profit, two-year college offering over two dozen associate degree programs. Students from 12 states and 15 countries live and learn at Ancilla.

Mail: P.O. Box 1, Donaldson, IN, 46513.

Location: 9601 Union Road, Plymouth, IN, 46563.

Call toll-free: 1.866.ANCILLA (866) 262-4552 or (574) 936-8898.

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Apply Online – Division of Nursing

Apply Online - Division of Nursing

Educational Background

Professional Experience

Accuracy Statement