Admissions

Indiana Dabney University

www.DabneyU.org

 

5217 South Hohman Avenue, Hammond, Indiana 46320 - (219) 932-2100 or 855-IDU-0880 Main Campus (219) 932-1647 Fax

Please Print or Type
Application for Admission

Date

 

 

Last Name

 

First Name

 

Middle Name

 

Primary Address

(complete street address)

 

Secondary Address

(complete street address)

 

Home Phone

(        )

 

 

Work Phone

(        )

 

 

Cellular Phone

(        )

 

 

Email address

 

Alternative email address

 

Emergency Contact person

(address, phone number and relationship)

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender

 

 

Drivers Licenses Number or State Identification Number

 

Social Security Number

 

Country of Origin

 

 

 

Passport or Visa Number (if applicable)

 

Date of Birth

 

 

 

Country of Birth

 

 

 

Are you a U.S. Citizen? (please circle)

Yes       No

 

 

If not a U.S. Citizen list Country of Citizenship

 

List Friends or Relatives that have attend or graduated for IDU

 

 

 

 

List all High School, College/University and Trade Schools attended

 

Institution Name and Address

Dates Attended and Degrees Earned

1.

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

Employment History

 

Name of Employer

Job Title

 

 

 

 

 

Duties

Reason For Leaving

 

 

 

 

 

 

 

 

 

 

Supervisor

Contact

(Complete Address & Phone Number)

 

 

 

 

 

 

May we contact your employer?

Circle one: Yes or No

 

Employment Date: Example (01-01-2012)

 

Start Date:________________________

 

End Date:________________________

 

Name of Employer

Job Title

 

 

 

 

 

Duties

Reason For Leaving

 

 

 

 

 

 

 

 

 

 

Supervisor

Contact

(Complete Address & Phone Number)

 

 

 

 

 

 

May we contact your employer?

Circle one: Yes or No

 

Employment Date: Example (01-01-2012)

 

Start Date:________________________

 

End Date:________________________

 

Name of Employer

Job Title

 

 

 

 

 

Duties

Reason For Leaving

 

 

 

 

 

 

 

 

 

 

Supervisor

Contact

(Complete Address & Phone Number)

 

 

 

 

 

 

May we contact your employer?

Circle one: Yes or No

 

Employment Date: Example (01-01-2012)

 

Start Date:________________________

 

End Date:________________________

 

Name of Employer

Job Title

 

 

 

 

 

Duties

Reason For Leaving

 

 

 

 

 

 

 

 

 

 

Supervisor

Contact

(Complete Address & Phone Number)

 

 

 

 

 

 

May we contact your employer?

Circle one: Yes or No

 

Employment Date: Example (01-01-2012)

 

Start Date:________________________

 

End Date:________________________

 

Name of Employer

Job Title

 

 

 

 

 

Duties

Reason For Leaving

 

 

 

 

 

 

 

 

 

 

Supervisor

Contact

(Complete Address & Phone Number)

 

 

 

 

 

 

May we contact your employer?

Circle one: Yes or No

 

Employment Date: Example (01-01-2012)

 

Start Date:________________________

 

End Date:________________________

 

Name of Employer

Job Title

 

 

 

 

 

Duties

Reason For Leaving

 

 

 

 

 

 

 

 

 

 

Supervisor

Contact

(Complete Address & Phone Number)

 

 

 

 

 

 

May we contact your employer?

Circle one: Yes or No

 

Employment Date: Example (01-01-2012)

 

Start Date:________________________

 

End Date:________________________

 

Name of Employer

Job Title

 

 

 

 

 

Duties

Reason For Leaving

 

 

 

 

 

 

 

 

 

 

Supervisor

Contact

(Complete Address & Phone Number)

 

 

 

 

 

 

May we contact your employer?

Circle one: Yes or No

 

Employment Date: Example (01-01-2012)

 

Start Date:________________________

 

End Date:________________________

 

Name of Employer

Job Title

 

 

 

 

 

Duties

Reason For Leaving

 

 

 

 

 

 

 

 

 

 

Supervisor

Contact

(Complete Address & Phone Number)

 

 

 

 

 

 

May we contact your employer?

Circle one: Yes or No

 

Employment Date: Example (01-01-2012)

 

Start Date:________________________

 

End Date:________________________

 

Program Applying for Admission

 

(Please check one)

_ Adult Vocational High School Diploma Program

 

_ Certified Nursing Assistant

 

_ Clinical Medical Assistant

 

_ EKG Technician

 

_ Pharmacy Technician

 

_ Phlebotomy Technician

 

_ Associate of Science Degree in Nursing (ASN)

 

_ Bachelor of Science in Business Administration

 

_ Master Degree in Business Administration

(MBA)

 

_ Master of Science Degree in Nursing (MSN)

 

_ Undergraduate Minor/Certificate Program (6

classes)

Title:____________________________

 

_ Graduate Minor/Certificate Program (6 classes)

Title:________________________________

 

_ Other

Title:________________________________

 

Ethnic Background & Religious Belief                                                                                                  (optional)

(  (Please check one)

 

__ Black or African American

 

__ White

 

__ Hispanic or Latino/Latina

 

__ American Indian or Alaska Native

 

__ Asian

 

__ Native Hawaiian or Other Pacific Islander

 

__ Asian

 

__ other  (Please List)________________________

 

__ Religious Belief (i.e. Christianity, Indian Religions, Islam, Buddhism)

 

Marital Status (optional)

(Please check one)

Single:__________

Married:________

Separated:_______

Divorced:________

 

 

 

Military Service

 

Military Status:___________________

 

Military Branch:__________________

 

 

Are you interested in joining the Men’s & Women’s Basketball team

(circle One)

 

Yes or No

 

Place of Birth:

 

City/Provence: ____________________ State: _________________ Country:__________________

Will you be applying for any financial assistance? ___yes   ____no

 

Will you be applying scholarship funds to offset your tuition cost? __yes  ___no

 

Will your employer pay all or part of your tuition? ___yes   ____no

 

Anticipated Enrollment Month ___________________

 

How did you hear about our academic programs?_______________________________________________________________________

Have you ever been convicted of a Felony?

Yes or No (if yes, explain below)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever been convicted of a Misdemeanor?

 

Yes or No (if yes, explain below)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you a Qualified Medical Assistant (QMA)?

Circle one: Yes or No

Are you a Certified Nursing Assistant (CNA)?

Circle one: Yes or No

Are you a License Practical Nurse (LPN)?

Circle one: Yes or No

Are you a Phlebotomy Tech?

Circle one: Yes or No

Is English a second language for you?

Circle one: Yes or No

 

Check the languages you can speak.

Other:

 

 

 

Check all that apply

 

Arabic

 

Greek

 

Spanish

 

Chinese

 

Italian

 

Swedish

 

Dutch

 

Japanese

 

Turkish

 

French

 

Latin

 

 

 

German

 

Russian

 

 

 

I certify that all the above information is true, without prejudice or misleading information. I further understand and agree to the policies and procedures of Indiana Dabney University, Inc. I further understand that these policies and procedures can change without notice. I also grant permission for my pictures to be used on the website or in printed materials. I further agree to pay in full all fees, including the application fees when due and further authorize this signature to be on file, for use in future credit card authorizations for the payment of fees. I certify that I have received a copy of the catalog and understand that it is updated without notice, but made available online and at the campus. I also understand that it is my responsibility to read and abide by its rules, policies and procedures of this University.

Fees to be submitted with Application:

Application Fee $100  non-refundable

(Applications are only valid for 8 – months  from the date it was received.)

Schedule Pre-Entrance Exam (only for nursing program applicants) the cost is included in the application fee (only valid for 8 – months  from the date it was received). However, if applicant fails to attend their scheduled date and/or time there is a $49 cost to reschedule the examination, if not rescheduled within 24 hours of the original date and time.

All Applicants Sign (Nursing applicants sign and continue the application)

_______________________________________________________________________________________

Applicant’s Signature                                                                                                             Date

 

Indiana Dabney University does not consider race, sex, sexual orientation, religion, or national origin in the selection process.

 

Currently we are authorized to seek and enroll students in our Certificate, Diploma and Degree Programs. Indiana Dabney University and its agents reserve the right to amend this document without notice.

Questions for Nursing Students Only:

Have you taken the Pre-Admission Exam? ___Yes ___No

 

Are you licensed or certified in the health care field ___Yes ___No

If yes, please supply license/certification number and state: (license/certification must be valid)

__________________________________________________________________________________________

 

List all “Health Care Experience” __________________________________________________________________________________________

 

_____________________________________________________________________________________

 

Have you ever been convicted of a misdemeanor or a felony? If yes, explain:___________________________________________________________________________________

 

_________________________________________________________________________________________

 

__________________________________________________________________________________________

Note: Students are subject to background checks throughout their academic career at Indiana Dabney University, at the student’s cost. Students with felony convictions and/or other arrest records are highly encouraged to contact the State Board of Nursing to see if this will negatively affect your ability to be licensed as a Nurse. We do not guarantee the State Board of Nursing’s approval.

 

I understand that the IDU School of Nursing admits a limited number of students due to available resources and/or faculty. Although I may meet or exceed the minimum requirements for admission, circumstances may prevent the Nursing School from admitting all students who meet the admission criteria. Furthermore, it is my responsibility to provide transportation to all clinical sites. Currently clinical sites are in Indiana and Illinois.

 

I understand it is my responsibility to check my University email daily, at least and that student grades, student financial information and other correspondences will be sent to the students university email account (other personal email accounts are not acceptable).

_______________________________________________________________________________________

Applicant’s Signature                                                                                          Date

Indiana Dabney University does not consider race, sex, sexual orientation, religion, or national origin in the selection process.

Currently we are authorized to seek and enroll students in our Certificate, Diploma and Degree Programs. Our nursing program is authorized by the Indiana Commission on Proprietary Education and the Indiana State Board of Nursing. We are not currently nationally or regionally accredited. Indiana Dabney University and its agents reserve the right to amend this document without notice.

In your own handwriting, please respond to the following: (1) list the things you have accomplished that have given you the greatest satisfaction, (2) list your reasons for selecting nursing as a career or to further your career as an RN, (3) list special reasons for desiring to enter this school, and (4) list your plans and aspirations for the future. Please use the back of this page if more space is required. Sign and date your response.

 

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature: _____________________________________________________________Date:________________________

University Use Only:

Application Received by:__________________________________________________________Date:_________________________________________