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Wicks Education Associates, Inc
Wound Care Specialty Program Application Form

Name

 Date
Address

 City

 St

 Zip
Home Telephone

 Work Phone

    
Employer
Address

 City

 St

 Zip
Social Security #

 Email Address
Current RN Licensure (State/Number)

 Date of Original RN Licensure

 

Program Selection
Site Program

 Class Date

 

Office Use Only

DATE RECEIVED   DATE SENT  
APPLICATION FORM   WELCOME LETTER  
HEALTH FORM   ORIENTATION PACKET  
HIPAA TRAINING   INVOICE SENT  
LIABILITY INSURANCE      
NURSING LICENSE   TUITION PAYMENT  
UNIVERSAL PRECAUTIONS      
COLLEGE TRANSCRIPT   APPLICATION FEE  
REFERENCE # 2  Ref.   TUITION  
CRIMINAL BACKGROUND CHECK   OTHER  

            

APPROVED FOR CLASS ACCEPTANCE: __________________________________________

 

EDUCATION

 

INSTITUTION LOCATION OF SCHOOL DEGREE AND GRADUATION YEAR GPA
       
       
       

Please note: If you do not possess a BSN, please complete the form attached (Documentation Record for NON-BSN Students).

FIVE YEAR EMPLOYMENT HISTORY

PRESENT EMPLOYER

 TELEPHONE
ADDRESS

 CITY

 ST

 ZIP
JOB TITLE

 DATES EMPLOYED
NATURE OF WORK PERFORMED, INCLUDING CLINICAL, EDUCATIVE AND ADMINISTRATIVE

 

 

PRESENT EMPLOYER

 TELEPHONE
ADDRESS

 CITY

 ST

 ZIP
JOB TITLE

 DATES EMPLOYED
NATURE OF WORK PERFORMED, INCLUDING CLINICAL, EDUCATIVE AND ADMINISTRATIVE

 

REFERENCES

NAME/ADDRESS & TELEPHONE NUMBER
NAME/ADDRESS & TELEPHONE NUMBER

STATEMENT OF CAREER GOALS AND OBJECTIVES

 

 

 

 

 

 

 

CLINICAL PRACTICUM

Wicks Educational Associates offers assistance in locating clinical preceptors in the student's geographical area after you have been accepted into the program. If you have conformed arrangements with a preceptor, please fill in the name, institution and telephone number of the certified WOC/ET or CWCN Nurse(s) below.

PRECEPTOR NAME AND INSTITUTION/ADDRESS & TELEPHONE NUMBER
PRECEPTOR NAME AND INSTITUTION/ADDRESS & TELEPHONE NUMBER

How did you learn about the program? __________________________________________________

 

Please submit the following to complete the application process:

           (individual policy, not through employer)

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.

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 Signature _____________________________________________________

 

Make check payable to Wicks Educational Associates, Inc

and mail to:

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

Please Note:  We recommend that you make a photocopy of this application and all other forms which 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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