CO-OP Application

First Name

Last Name and Middle Initial

Local Address

Local City

Local State

Local Zip Code

Permanent Address

Permanent City

Permanent State

Permanent Zip Code

Home Phone

Cell Phone

E-mail Address

Birth Date

Tribe

Enrolled or Descendant

Marital Status

Spouse's Name

Number and Ages of Children

Have you Completed a CNA course? If so, When/Where?

Are You Currently Licensed as a Nurse?

Yes

Date of Acceptance to MSU

Please Check One

B.S.N

AD/RN

Diploma RN

AD/LPN

1 yr LPN

Have You Been Admitted to MSU's College of Nursing Upper Division?

Yes

If yes, Which semester/yr?

How did you hear about the CO-OP?

Friend/Relative

Teacher/Counselor

Rockin-the-Rez

Conference

Mail

Internet/Website

Facebook

Other

Undergraduate

Freshman

Sophomore

Junior

Senior

Graduate

Doctor of Nursing Practice Family Individual Nurse Practitioner

Doctor of Nursing Practice Psychiatric Mental Health Nurse Practitioner

Masters of Nursing Clinical Nurse Leader (CNL) *no I.H.S. support for CNL option

High School Attended

Graduation Date

City of High School

State of High School

List all Community/Technical/University/Colleges attendedInclude Name, Address, Date, and Degree

Have you been Tested for Learning Disabilities

Yes

If yes, What was the Diagnosis?

List needed Accommodations, if any:

In accepting CO-OP support services and selecting yes, I agree to the following monitoring procedures of the CO-OP throughout my academic program.

Intensive Advising: I agree to allow CO-OP staff release of information to and from University offices, College of Nursing faculty, community agencies, and tribal offices to CO-OP for monitoring of satisfactory progress and financial stability
Moral Agreement: I agree to mandatory lecture, laboratory, and clinical attendance to show commitment towards admittance to a nursing program or completion of a nursing program and to ensure satisfactory progress of pre-nursing or nursing curriculum
Photo, Video, Voice Permission: I agree to allow CO-OP to take and use my photo, video or voice for educational, media, and publication purposes.

Please Check Yes or No

Yes

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