baptist health schools little rock

APPLICATION PROCESS Step 1: Submit completed Application Form. Step 2: Take appropriate pre-admissions testing for the desired program. Step 3: Request Official Transcripts from ALL previous educational institutions (including high school).

Selection for entry into the BAPTIST HEALTH Schools Little Rock is determined by the appropriate program’s Selection Committee, by use of rating methodology.

PROGRAM FOR WHICH YOU ARE APPLYING: ____ Histotechnology ____ Registered Nursing ____ Medical Technology ____ RN Accelerated Option*____ Nuclear Medicine Technology ____ Sleep Technology ____ Occupational Therapy Assistant ____ Surgical Technology ____ Practical Nursing * must be an LPN, LPTN____ Radiography or Paramedic to apply

Date of Application: _________________ Term of Desired Admission: ______________

Name: _____________________________________________________________________________________ (FIRST) (MI) (LAST) (MAIDEN)

Other Name(s): ______________________________ Social Security Number: _______________________

Current Address:_____________________________________________________________________________ (STREET) (CITY) (STATE) (ZIP)

Permanent Address (if different): _______________________________________________________________ (STREET) (CITY) (STATE) (ZIP)

Telephone Number: (_____) _________________ Alternate Telephone Number: (_____) ________________

Email Address: ______________________________________________________________________________

Name of Parent(s) or Legal Guardian(s) (if under 18 years of age):______________________________________

Have you previously applied to BAPTIST HEALTH Schools Little Rock? ____ Yes ____ No

If yes, for which program did you apply? __________________

Have you previously attended BAPTIST HEALTH Schools Little Rock? ____ Yes ____ No

If yes, which program did you attend? _____________________ Dates Attended: _____________________

Have you previously attended another nursing or allied health program of study? ____ Yes ____ No

If yes, what was your reason for leaving? _______________________________________________________

BAPTIST HEALTH Schools Little Rock “A Commitment Beyond Academics”

11900 Colonel Glenn Road Little Rock, AR 72210

501-202-6200 1-800-345-3046 www.baptisthealthschools.org

APPLICATION FOR ADMISSION

Have you ever been convicted of a misdemeanor, felony, or plead guilty or nolo contendere to any charge in any state or jurisdiction? (BAPTIST HEALTH Schools Little Rock defines a crime as all criminal offences, misdemeanors and is not limited to felonies. DWI is considered a crime.) _____ Yes _____ No

Are you a resident of Arkansas? ____ Yes ____ No If “Yes”, how many years/months? _________________

Is English your native language? ____ Yes ____ No If “No”, results of TOEFL are required.

If selected for entry, can you provide proof that you are either a U.S. citizen, or otherwise legally permitted to reside in the United States? ____ Yes ____ No

Please list in chronological order any educational institutions you have attended, including high school, beginning with the most recent. Official transcripts from ALL educational institutions attended are required. Please attach a separate sheet of paper if additional space is needed. ALL includes Colleges, Universities, Vocational Schools, Private Schools, Military Schools, Private Career Schools, etc.

Name of Institution City/State Dates Attended Degrees/Certificates

***If you are currently enrolled in an educational institution, please provide an in-progress transcript.

Have you ever been terminated from a patient care facility (including BAPTIST HEALTH)? ____ Yes ____ No

If Yes, dates of employment: _________________________________________

Reason for Termination: __________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________

Please list in chronological order all employment held within the past FIVE (5) years. If you need additional space, please attach a separate sheet or resume.

Employer City/State Dates Employed Job Title Reason for Leaving

I hereby make application for selection to the BAPTIST HEALTH Schools Little Rock and declare that the information on this application is complete and accurate. I understand that any misrepresentation, falsification, omission of information, or any other attempt to deceive the school is cause for either denial of selection for entry or dismissal from enrollment and that any future application(s) shall not be considered by the BAPTIST HEALTH Schools Little Rock. In addition, I also hereby give Baptist Health permission to conduct a criminal background check and social security number verification.

Applicant Printed Name: _____________________________________________________________

Applicant Signature: _________________________________________ Date: _________________

BAPTIST HEALTH does not discriminate on the bases of age, color, creed, physical challenges, gender, marital status, national origin, race, or religion.

EDUCATIONAL HISTORY

EMPLOYMENT HISTORY

NOTE TO APPLICANT: This information is used for statistical and reporting purposes only, and does not in any way affect the eligibility for selection. This information will not be shared with selection committees.

Name: __________________________________________ Social Security Number:__________________________

Marital Status:

____ Single ____ Married ____Separated ____ Divorced ____ Widowed

Religious Preference: ____________________________________ Sex: ____ Male ____ Female

County of Permanente Residence: __________________________

Predominant Ethnic Background: ____ American Indian/Alaskan Native ____ Asian or Pacific Islander ____ Black, Non Hispanic ____ Hispanic/Latino ____ White, Non Hispanic ____ Other:_______________________

Residence Status: ____ U.S. Citizenship

____ Permanent Resident ____ Resident Alien ____ H-1 Visa ____ Other:_____________________

Date of Birth:

________/________/_______________ MM DD YYYY

APPLICANT SIGNATURE: ________________________________________ DATE: ________________

Revised 11/2007 RFA BHSNAH_Share

DEMOGRAPHIC DATA

You have a question. We have the answer.

General questions about BHSLR or our programs... 501-202-7951

Questions about admissions or your application... Histotechnology... 501-202-7740

Medical Technology... 501-202-7740 Nuclear Medicine Technology... 501-202-7740

Occupational Therapy Assistant... 501-202-7740 Practical Nursing... 501-202-7448

Radiography... 501-202-7740 Registered Nursing-Traditional Option... 501-202-7487

Registered Nursing-Accelerated Option... 501-202-7446 Sleep Technology... 501-202-7740

Surgical Technology... 501-202-7740

Questions about financial aid or scholarships......... 501-202-7457 ......... 501-202-7986

Questions about transfer courses or transcripts..... 501-202-7933

Questions about payment options.......................... 501-202-7430 .......................... 501-202-7848

www.baptisthealthschools.org

Thank you for choosing BAPTIST HEALTH Schools Little Rock. Please take a few moments and let us know what you thought of our performance. In order to insure anonymity, please return in a separate envelope.

This document is NOT mandatory in order to complete your application, nor do you have to be an applicant to return this document.

SURVEY

Did you receive requested information in a timely manner?

YES NO

Were you treated courteously by our staff?

YES NO

How did you receive your information?

Mail Website Picked up in person Other:__________________________________

Were all of your questions answered to your satisfaction?

YES NO

If you used our website, did you find it user-friendly?

YES NO

How did you hear of BAPTIST HEALTH Schools Little Rock?

Newspaper or Magazine Website or Search Engine Friend or Family Member

Special Event:________________________________________________

Other:______________________________________________________

Do you intend on completing the application process? YES NO

If no, what is the primary reason for not completing the application process?

Financial or personal reasons Decided to attend different educational institution

No longer interested in attending school Baptist Health did not offer desired program of study

Dissatisfied with customer service Other:___________________________________

COMMENTS

Do you have any suggestions to improve BAPTIST HEALTH Schools Little Rock application process?

Other comments or suggestions:

Revised 4/2007 RFA J:BHSNAH_Share

BAPTIST HEALTH Schools Little Rock

Prospect and Applicant Survey

* “Official Transcript” means that the completed transcript is sent directly to BAPTIST HEALTH Schools Little Rock from the otherinstitution and contains the institutions official seal.

Revised April 2007 RFA J:BHSNAH_Share


Transcript Release Form 11900 Colonel Glenn Road

Little Rock, Arkansas 72210-2820 501-202-6200 1-800-345-3046

501-202-6220 (fax)

APPLICANT: Use this form to request official transcripts* from ALL high schools, colleges, universities, vocational schools, private schools, military schools, etc. you have attended. To request a GED transcript, send this form to: GED Testing Services, Adult Education Section,

Luther Hardin Building #601, #3 Capitol Mall, Little Rock, AR 72201, Telephone: 501-682-1978.

CHECK SCHOOL TO WHICH APPLICATION IS BEING MADE: ___ Histotechnology ___ Radiography ___ Medical Technology ___ Registered Nursing Traditional ___ Nuclear Medicine Technology ___ Registered Nursing Accelerated ___ Occupational Therapy Assistant ___ Sleep Technology ___ Practical Nursing ___ Surgical Technology

REGISTRAR: Return this form with an official transcript with seal attached to the address above.

NAME: ______________________________________________________________________ Last First MI Maiden Other Surname(s)

Name as listed on Transcript: ____________________________________________________

Social Security Number: _______________________ Date of Birth: ____________________

Current Address: ______________________________________________________________ Street City State Zip

Name of Institution: ___________________________ Date(s) Attended: _______________

Applicant Signature: ____________________________________ Date: ________________.3


2008 Applicant Testing

TESTING FAQs:How do I sign-up to take the ACT and/or NET at BAPTIST HEALTH Schools Little Rock?

To sign-up for testing at BAPTIST HEALTH Schools Little Rock, please call our admissions office at 501-202-6200 or 1-800-345-3046, or register online at www.baptisthealthschools.org. Remember that your application must be on file prior to testing.

What do I bring the day of the test? The day of testing, you will need your $35.00 testing fee (or $70.00 testing fee if taking both) in cash, check or money order and two #2 pencils. Wear comfortable attire and arrive at least thirty minutes prior to testing.

I took the ACT many years ago. Do I need to re-test? BAPTIST HEALTH Schools does not require students with old ACT Scores to re-test. However, you may prefer to re-test for scholarship or admissions purposes.

Can I have my score(s) sent to other institutions? Because BAPTIST HEALTH Schools Little Rock is a residual testing site, your ACT and/or NET scores may not be used at another institution.

Do you accept the Compass Test? BAPTIST HEALTH Schools Little Rock does not accept the Compass Test. The only test that may be substituted for the ACT is the SAT.

ACT TEST NET TEST American College Test Nurse Entrance Test

Required for admission to ALL programs of study

Required for admission to nursing programs

3 ½ hours in length 2 ½ hours in length

$35.00 testing fee $35.00 testing fee

MONTHTuesday6:30 p.m. NET ONLY

Thursday 8 a.m. ACT 1 p.m. NET

Saturday8 a.m. ACT 1 p.m. NET

February 5 7 2

March 25 27 29

April 22 10, 24 26

May 6, 13 15 17, 24

June 17 19 21, 28

July 1, 15 17 19

August --- --- ---

September 16 18 20

October 21 23 18

November 18 20 22

PLEASE NOTE: Application MUST be on file prior to testing.

If you took the ACT or SAT previously and is not reflected on your high school transcript, telephone or write to the specific testing company to request a score be sent to the BAPTIST HEALTH Schools Little Rock. A fee may be charged by

the testing company for this service.

ACT SAT 319-337-1313 609-771-7600 www.actstudent.org www.collegeboard.com

For more information on applicant testing, or to sign up for a testing date, please call the BAPTIST HEALTH Schools Little Rock Admissions Office at 501-202-6200 or 1-800-345-3046 or visit www.baptisthealthschools.org.

2008 TESTING DATES

MEMORANDUM

TO: Occupational Therapy Assistant Applicant

FROM: BAPTIST HEALTH School of Occupational Therapy Assistant

DATE: August 2006

SUBJECT: Required volunteer/observation experience

The BAPTIST HEALTH School of Occupational Therapy Assistant (BHSOTA) requires a volunteer/observation

experience for all program applicants. This experience must be for at least 20 hours and may be completed

in any occupational therapy setting under the supervision of a registered occupational therapist (OTR) or

certified occupational therapy assistant (COTA). It is the responsibility of the applicant to make

arrangements with an occupational therapist for this experience. The applicant is also responsible for

obtaining the Volunteer Work Evaluation Form from the BHSOTA giving it to the supervising therapist. This

requirement must be met and all forms returned by the application deadline.

Guidelines for the volunteer experience are as follows:

1.

2.

3.

4. The evaluation form MUST be received prior to the application deadline.

5. Each of the required 20 hours of observation MUST be completed within one facility.

6.

7.

The applicant makes arrangements with a registered occupational therapist to

complete the 20 hours of volunteer work or observation. It is up to the applicant and

therapist to agree on the schedule for these hours (i.e., 4 hours a day, 2 hours a week,

etc.). This is a voluntary service provided by the therapist. Therapists are NOT

obligated to provide this experience.

The applicant gives the occupational therapist the evaluation from the first day of the

volunteer experience.

Once the volunteer experience is finished, the occupational therapist completes the

evaluation form and mails it directly to the BHSOTA.

Observation hours must be dated within the current year or the year preceding the

application. For example, an applicant for the 2007 class must have observation hours

completed within 2006 or 2007.

Applicants will not be allowed to use current or previous work site as observation hours,

nor can an applicant observe under a therapist who is a family member or friend.

VOLUNTEER WORK EVALUATION FORM

Applicant’s Name__________________________________________ Date:_____________

In requesting the completing of this evaluation form which will be used in the admission selection

process for the occupational therapy program at the BAPTIST HEALTH School of Occupational Therapy

Assistant. I waive my right of access to this document

______________________________________________________________________________

(Applicant signature)

OTR completing this form ______________________________________________________

Facility & Address ______________________________________________________

______________________________________________________

Number of volunteer/observation hours completed at your facility:________________________

Instruction: Please circle the number closest to the best description of the student.

WORK HABITS

1.1 Attendance 1 2 3 4 5Poor attendance Attends regularly,

Often late on time makes proper arrangements

1.2 Ability to follow 1 2 3 4 5 direction Frequent mistakes Follows multiple step

directions correctly1.3 Efficiency 1 2 3 4 5

Slow, disorganized Completes task in prompt,efficient manner

INTERPERSONAL SKILLS

2.1 Attitude toward patient 1 2 3 4 5Rude, careless inappropriate, Pleasant &overly involved, fearful, etc. appropriate

2.2 Attitude toward stuff 1 2 3 4 5Inappropriate, sullen, Cooperative,disrespectful, cavalier respectful

2.3 Communication Skills 1 2 3 4 5Ineffective, poor verbal skills, Effective, clear,unclear, poor listener concise

2.4 Affect/Emotional 1 2 3 4 5 Response Labile/immature Mature, empathetic

negative, inappropriate

WORK BEHAVIOR

3.1 Motivation 1 2 3 4 5Unmotivated, disinterested Good motivation desire to learn

3.2 Personal appearance 1 2 3 4 5Sloppy, too casual, overly Complies withdressed, too revealing, etc. regulations of site

3.3 Acceptance of role 1 2 3 4 5as volunteer Poor-has difficulty with Excellent-accepts

role as volunteer role without question3.4 Dependability, 1 2 3 4 5

Re liablility Poor-no consistency Excellent-selfdependent on others starter, dependable

3.5 Patient/client 1 2 3 4 5confidentiality Problems maintaining Understands &

confidentiality respects patient confidentiality no problems

PERFORMANCE COMPONENTS

4.1 Task completion/ 1 2 3 4 5physical performance Problems evident, Completes tasks

without sloppy, difficultyuncoordinated

4.2 Problem solving ability 1 2 3 4 5Poor, unable to Excellent,recognize problems demonstratesConcrete thinking abstract reasoning,

anticipates problems responds as appropriate4.3 Judgement (Safety of 1 2 3 4 5

self & other actions) Poor, lacks insight Excellent, insight

SUMMARY

5.1 Areas in which volunteer needs to improve:

5.2 Volunteer's strengths:

5.3 Comments:

Please return the completed form to:BAPTISTHEALTHSchoolof Occupational Therapy Assistant,11900 Colonel Glenn Road, LittleRock,Arkansas72210

Reference: University of Central Arkansas, Department of Ocupational Therapy.

baptist health schools little rock

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