Admissions Application Request - Main Form

Program Information
Contact Information
Personal Information
Education History
Background & Licensure
Acknowledgement

is required

is Required

First Name (as it appears on your government issued ID)
Middle Name (as it appears on your government issued ID)
Last Name (as it appears on your government issued ID)
Email Address
Social Security Number
Date of Birth
Gender
Are you Hispanic or Latino?
Select one or more of the following races:

White

Black or African American

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander
Citizenship Status
Place of Birth
Marital Status
By checking this box I agree to receive recurring SMS messages from ICHS to the provided mobile number. Standard message & data rates may apply.

is Required

Physical Address & Phone Number(s)
Country
Street 1
Street 2
City
State
Zip Code Zip Code Extension
Province
Postal Code
Home Phone Home Phone Area Code Home Phone Exchange Home Phone Number Home Phone Extension Ext:
Home Phone Home Phone Extension Ext:
Cell/Mobile Phone Cell/Mobile Phone Area Code Cell/Mobile Phone Exchange Cell/Mobile Phone Number Cell/Mobile Phone Extension Ext:
Cell/Mobile Phone Cell/Mobile Phone Extension Ext:
Mailing Address
Copy Home Address Into Mail Address
Mail Country
Mail Street 1
Mail Street 2
Mail City
Mail State
Mail Zip Code Mail Zip Code Extension
Mail Province
Mail Postal Code

is Required

is Required

Highest Level of Education
High School or GED
College Attended
College Attended
College Attended
Section 456.0635., Florida Statutes

Important Notice for Initial Licensure Applicants and Renewals:
Effective July 1,2012, Section 456.0635, Florida Statutes, provides that health care boards or the department shall refuse to issue a license, certificate or registration and shall refuse to admit a candidate for examination if the applicant:
(2) Each board within the jurisdiction of the department, or the department if there is no board, shall refuse to admit a candidate to any examination and refuse to issue a license, certificate, or registration to any applicant if the candidate or applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant.
(a) Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 817, or chapter 893, or similar felony offense committed in another state or jurisdiction, unless the candidate or applicant has successfully completed and drug court program for that felony and provides proof that the plea has been withdraw or the charges have been dismissed. Any such conviction or plea shall exclude the applicant or candidate from licensure, examination, certification, certification, or registration unless the sentence and any subsequent period of probation for such conviction or plea ended.
1. For felonies of the first or second degree, more than 15 years before the date of application.
2. For felonies of the third degree, more than 10 years before the date of application, except for felonies of the third degree under s. 893.13 (6)(a).
3. For felonies of the third degree under s. 893.13 (6)(a), more than 5 years before the date of application,
(b) Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the sentence and any subsequent period of probation for such conviction or plea ended more than 15 years before the date of the application;
(c) Has been terminated for cause from the Florida Medicaid program pursuant to s. 409.913, unless the candidate or applicant has been in good standing with the Florida Medicaid program for the most recent 5 years;
(d) Has been terminated for cause, pursuant to the appeals procedures established by the state, from any other state Medicaid program, unless the candidate or applicant has been in good standing with the state Medicaid program for the most recent 5 years and the termination occurred at least 20 years before the date of the application; or
(e) Is currently listed on the United State Department of Health and Human Services Office of Inspector General’s List of Excluded Individual and Entities.
NOTE: This section does not apply to candidates or applicants for initial licensure or certification who were enrolled in an educational or training program on or before July 1, 2009, which was recognized by a board or, if there is no board, recognized by the department, and who applied for licensure after July 1, 2012.
Program of Interest
Any statement made on this application that is false and known to be false by the applicant at the time of making such statement shall be deemed fraudulent and my subject the applicant for disciplinary proceedings.

Admission to any nursing program may be denied based on the results of the criminal background check drug screening, and /or previous academic history, behavior.
You agree to submit to consumer credit reports, as needed, for financial and purposes.
All students entering nursing core concentration course must have on file a current American Heart Association Healthcare Provider CPR certification that is outlined in the School Of Nursing Handbook.
All students must submit documentations and proof of immunity for Hepatitis Be; Varicella; Measles, Mumps, and Rubella. Students are required to have season flu and current Tetanus, Diphtheria, and Pertussis vaccination; and Tuberculosis screening. A health physical must also be submitted. For Additional information regarding health requirements and documentation please refer to the School of Nursing Handbook and Catalog. These requirements are subject to change without notice. Students are financially responsible to meet current and required health requirements.
All students must have a cleared background and negative drug screen through Certified Background. For further details please refer to the School of Nursing Student Handbook and Catalog.
Please read each statement below:
1) I understand that it is my responsibility to familiarize myself with the School of Nursing and Graduate Studies Handbook and College Catalog.
2) I am aware of the practicum/ clinical requirements outlined in the College Catalog and School of Nursing and Graduate Studies handbook and I can fulfill the requirements.
3) I am aware that clinical hours may be scheduled for evenings, overnight, weekends, and holidays. The College may not be able to accommodate special clinical schedule requests.
4) I am aware of the physical and mental capabilities outlines on the Functional Health and Abilities form and I attest that I am able to meet these requirements.
5) I am aware if there is a change to my physical and / or mental health capabilities outlined on the functional health and abilities form that will affect my ability to meet the requirements as a student, I will notify the Dean of Nursing within 24 hours.
6) I am aware of the admission requirements as outlined in the College Catalog and understand that all requirements must be met for admission consideration.
7) I am aware curriculum modifications or changes may occur to include policies and procedures during my enrollment.
8) I am aware of the nursing programs current program outcomes. The current licensure pass rate can be reviewed at https://appsmqa.doh.state.fl.us/MQASearchServices/Home.
I certify that the information I have provided on this application is the true and accurate. I have read each statement and attest that I am aware and agree with each statement.
Desired Start Date
Are you a United States Veteran?
Please check this box if you are the first person in your immediate family to attend college

is Required

If you currently hold an active healthcare provider license in Florida or any other state, please provide 1) License type, 2) License Number, 3) State Issued, 4) Expiration Date
Check this box if you are a Chiropractor
Check this box if convicted of, or entered a plea of guilty, nolo contendre, or no contest to any crime in any jurisdiction other than a minor traffic offense:
Please check this box if you have ever been denied or is there now a proceeding to deny your application for ANY healthcare license to practice in Florida or any other stat, jurisdiction or country:
Please check this box if you have ever been dismissed from a nursing program related to academic dishonesty, unprofessional behavior, attendance and/or clinical performance.
Check the box if you had an investigation or disciplinary action takes against your license to practice ANY healthcare related profession by a licensing authority in any state, jurisdiction or country
Check this box if you are a current LVN/LPN/Psych Tech
Check this box if you are a foreign medical doctor
Please type your full name and today's date:
How did you hear about International College of Health Sciences?
Check the box if you have ever surrendered a license to practice any healthcare related profession in any state, jurisdiction or country while such disciplinary charges were pending against you:
Are you are a former student applying as a re-entry?

Please check this box if you are a former student reapplying as a re-entry
I certify that the information I have provided on this application is the true and accurate. I have read and understand the application and Catalog. I have read each statement and attest that I am aware and agree with each statement.

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You will be asked to pay your $150.00 Application Fee after submission of your application