WEA home Wicks

 

Directions for application:

  1. Please print this page according to your browser's directions. 
  2. PRINT or TYPE the complete application
  3. Print the Physical Examination form and/or the Insurance Form according to your browser's directions, and have a licensed health care practitioner complete it in full. 
  4. Mail the completed application, physical examination, and all required documents, and the application fee to:

            Wicks Educational Associates, Inc.
            Maple Building
            Suite 202
            5012 Lenker Street
            Mechanicsburg, PA 17050

Checklist

Please submit the following to complete the application process:

_____ Completed application form
_____ Completed health forms
_____ Resume
_____ Official college transcript
_____ Copy of nursing license
_____ Two recommendations (using provided reference forms)
_____ Proof of professional liability insurance (individual policy, not through employer)
_____ Proof of completion of Universal Precautions education within the past 12 months
_____ Non-refundable application fee of $75
_____ HIPAA Training/ Course

_____ Criminal Background Check

NOTE: It is not necessary to mail all required documentation at the same time. You may submit the completed application form and application fee in order to hold a space in the program; additional documents may be mailed in separately. You will be notified of your acceptance into the program upon receipt of all required documentation.
Date: __________________
Name: ________________________________________________________
Last First

Middle
Home address: ________________________________________________________
________________________________________________________
Telephone: ____________________________ Fax: ___________________
Social Security No: _________________________ E-Mail: ____________________

EDUCATION

Name of Institution City/State Dates Diploma/Degree
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Current RN Licensure ___________________________ ____________________
State/Number State/Number
Date of Original RN Licensure ____________________________ ____________________
State                         Date Number

REFERENCES

Please have the following references complete the required reference forms and return them to Wicks Educational Associates, Inc., along with your application

1.  ______________________________________ _________________________________
   Name Telephone
   ______________________________________________________________________________
   Address
2.  ______________________________________ _________________________________
   Name Telephone
   ___________________________________________________________________________
   Address

RECORD OF EMPLOYMENT

________________________________________________________________________
Current Employer    Phone
________________________________________________________________________
Address
________________________________________________________________________
Position Held                                               Dates of employment

Nature of work performed, including clinical, educative and administrative

 

 
________________________________________________________________________
Previous Employer                                 Phone
________________________________________________________________________
Address
________________________________________________________________________
Position Held                                               Dates of employment

In the space below, write a statement of your career goals and objectives:

 

 

 

 

 

 

 

 

 

Please Identify the type of program for which you wish to apply:

On-Site Program:

Class Choice:

First:

 __________________________

Second

 _______________________

Date/Location

 Date/Location

Home Study Program

Anticipated Start Date: _____________________________

Combination Home Study/On-Site Program

Home Study: Anticipated Starting Date: __________________________
On-Site: Location(s)/Date(s) __________________________

 

Clinical Practicum

Wicks Educational Associates offers assistance in locating clinical preceptors in the student's geographical area. Please call our office at 1-800-807-WICKS.

If you have confirmed arrangements with a preceptor, please fill in the name, institution and telephone number of the certified WOC Nurse(s) below:

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

How did you learn about the program? _______________________________

 

 

Students are accepted without discrimination in regard to age, creed, ethnic origin, marital status, race, sex or sexual preference.

The statements I have made in this application are correct to the best of my knowledge I understand that any misrepresentation or omission of facts called for on this application is cause for cancellation of the application.

Applicant's Signature ______________________________

 

Make check payable to Wicks Educational Associates, Inc

Please Note:  We recommend that you make a photocopy of this application and all other forms you submit to Wicks Educational Associates, Inc., in the event that your precepting institution requires copies of certain documents.

 

 

 

 

 

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© 2004 All Rights Reserved
Wicks Educational Associates, Inc., Maple Building, Suite 202, 5012 Lenker Street, Mechanicsburg, PA 17055; Phone: 1.800.807.WICKS or 717.737.2770; Fax: 717.737.7683; E-Mail: wicks@epix.net

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