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Admission Application
Complete the admission application and submit along with credit card information for the $50.00 non-refundable application fee.
Instructions:* Signifies optional fields or sections where information not required
Personal Information
Name (First Middle Last):
First: Middle:
Last:
Application Date
Wednesday Mar 29, 2017 at 2:08:48 AM
Have you ever had another name(s)? (i.e. Maiden)

If yes, give name(s):
Social Security
Your social security number is being collected in compliance with the Dept of Education, the federal financial aid regulations, Federal Trade Commission and the truth and lending laws. Your personal identification number will be kept confidential in compliance with the FTC and the Gramm-Leach-Gliley Act (GLB).
Number (000-00-0000)

E-mail Address
Date of Birth (mm/dd/yyyy)
Gender
Male Female
Current Street Address

Current City:
Current Zip:
Current State: Current County (if Iowa):
Is your Permanent Address the same as your Current Address?
Permanent Street Address

Permanent City:
Permanent Zip
State: Permanent County:
(if Iowa)
Primary Phone
555-555-5555
Work Phone (optional)
555-555-5555
Cell Phone (optional)
555-555-5555
Country of Citizenship:
USA Other, please specify:
If you are not a U.S. citizen, are you a permanent resident of the U.S.?
Yes No
If NO, enter your Alien Registration Number
A-
If you are not a U.S. citizen, are you a lawfully admitted alien?
Yes No
If you are not a U.S. citizen, what is your visa type? Student Exchange Visitor Permanent Resident
Other, please specify:
Is English your native language?
Yes No, please explain:
Ethnic Origin? (Optional)*
Alaskan Native or American Indian, Tribal/Nation Affiliation:
Hispanic/Latino(a)
Caucasian/White, not of Hispanic/Latino(a) origin
African American/Black
Asian or Pacific Islander
Emergency/Family Contact Information
Parent Spouse Legal Guardian
Other, please specify:
Contact Name (First Last):
First:
Last:
Contact Street Address

Contact City and State
City:
State:
Contact Zip
Contact Phone
555-555-5555
Contact Country:
USA Other, please specify:
Please be informed that licensure or certification may be sanctioned for conviction of a crime including a felony, a gross misdemeanor, or misdemeanor with the exception of speeding and parking violations. Additionally, acceptance and successful completion does not guarantee licensure, certification, or employment, which may be contingent on factors unrelated to the education process.
1. Do you have a record of convicted child or dependent adult abuse? Yes No
2. Have you ever been convicted of a crime in this state or any other? Yes No
3. Are you currently incarcerated? Yes No
4. Have you ever been excluded from or served with notice of exclusion from any governmental programs, i.e., medicare, medicaid, financial aid, loan default? Yes No
If yes to any questions, explain and give dates:
Education
Official transcripts from high school, all colleges and/or technical schools if attended are required for admission to St. Luke's College and should be sent directly from the respective school to the admissions office.
Name of School Address Date of Entrance
MM/YYYY
Date of Leaving
MM/YYYY
List Diploma or Degree Received
General Education Diploma (GED)
High School
College
College
College
College
College
Other
Admission Information
Instructions: To be considered for admission to St. Luke's College, the applicant must submit the following:
  • Completed Application Form
  • Official high school transcript or GED grade report.
  • Official scores from ACT (American College Testing) Examination.
  • Official college transcripts (if applicable).
  • Credit card information for non-refundable $50.00 application fee.
Desired Date of Enrollment: Fall (August) Spring (January) Summer (May)
Year of Enrollment:
Program(s) to which you are applying:
Bachelor's Degree Associate Degrees Certificate Advanced Radiology Specialties
(must be a registered radiologic technologist to be eligible for enrollment in a speciality program)
  • Bachelor of Science in Nursing (RN to BSN)
  • Bachelor of Health Science (BHS degree completion)
  • Nursing
  • Radiologic Technology
  • Respiratory Care
  • Phlebotomy
  • CT - Computed Tomography
  • MRI - Magnetic Resonance Imaging
  • Mammography - RT(R) required
  • Sonography
Are you currently: Registered Licensed Certified N/A
Identify type: License Number:
Exp Date: State
Current Professional Certification Title
Credentialing Organization Renewal Date
Current Employer
Name Location Position
Are you planning to apply for financial aid? Yes No
How did you become interested in applying to St. Luke's College?
Advertisement Alumni College Visit/Career Fair Counselor
Currently Enrolled or working at UnityPoint Health Affiliate Faculty/Staff Friends Family Member
Health Care Professional High School Visit UnityPoint Health or Affiliate Staff Internet
Mailings Pastor Other, please specify:
Have you taken or are you scheduled to take the American College Test (ACT) or the Scholastic Aptitude Test (SAT)?
SAT Yes No
If yes, indicate month and year:
Month Year
ACT Yes No
If yes, indicate month and year:
Month Year
In the area below please write an account of each of the items below:
  • Educational goals
  • Plans and aspirations for the future
  • Life Accomplishments
Application Payment
Please charge my
Card Number
Expiration Date
Credit Card Billing Address

City:
State:
Zip
St. Luke's College
Admission Office
2720 Stone Park Boulevard
SiouxCity, IA 51104
college@stlukescollege.edu
(800) 352-4660 ext 3149
(712) 279-3149
Fax: (712) 233-8017
http://www.stlukescollege.edu/

Iowa Administrative Code 655-2.11(152) requires a nursing program to initiate criminal history and dependent adult abuse record checks of students and prospective students to ensure a student?s ability to complete the clinical education component of the program.

Iowa Administrative Code 147.3 requires all individuals seeking nursing licensure by initial examination or endorsement who have criminal conviction(s), other than a minor traffic violation, to submit copy(s) of the sentencing order(s) when submitting application materials.

Iowa Administrative Code 655-2.8(5) states that students and prospective students (a) who have been denied licensure by the board, (b) whose license is currently suspended, surrendered or revoked in any U.S. jurisdiction or (c) whose license/registration is currently suspended, surrendered or evoked in another country due to disciplinary action may not take the clinical component of nursing courses. Students must notify the Department Chair, Nursing Education if they are in violation of this code.

St. Luke's college does not discriminate on the basis of race, color, creed, marital status, gender, age, national and ethnic origin or qualified disability and is in compliance with the Family Educational Rights and Privacy Act of 1974 as amended as well as the Drug Free Workplace Act of 1988.

Note: Licensing boards consider past felony convictions of applicants for licensure. A prior conviction does not automatically bar an individual from eligibility for licensure. Documentation may need to be presented.


Checklist: The following items are required to complete your admission file:
Official High School Transcript or GED Typed Summary
ACT/SAT Scores (if applicable) $50.00 Application Fee
Official College Transcripts (if applicable)


Official transcripts from high school, colleges, and/or technical schools are required for admission and should be sent directly from the respective school to the Admissions Office at St. Luke?s College. Transcripts are used for academic evaluation and become the property of St. Luke?s College and will not be reproduced, reissued or returned.


I certify that the above information is true and complete to the best of my knowledge.



Applicant/Electronic Signature
Type in your name


Date
Type in the Date (mm/dd/yyyy)