7-13_Sandy_Hernandez-signed.pdf

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UNITEK COLLEGE 888 735.4355 | www.unitekcollege.edMain Campus: 4670 Auto Mall Parkway, Fremont, CA 94538

Branch Campus:1901 Charcot Ave, San Jose, CA 95131

Branch Campus: 1111 Howe Ave, Suite 300, Sacramento CA 95825

Copyright Unitek College Version 2015.02.20 Page 1of 27

VOCATIONAL NURSING PREREQUISITES PROGRAM ENROLLMENT AGREEMENT DATE: April 14, 2015

DOB: 05/04/1974 STUDENT NUMBER: 209989

STUDENT NAME (LAST, FIRST):Hernandez, Sandy

STREET ADDRESS: 1120 sherman st

CITY:San Jose STATE: CA ZIP:95110

HOME TELEPHONE #:408-781-8420 MOBILE TELEPHONE#:EMA IL: [email protected]

PROGRAM SCHEDULE PROGRAM DURATION TUITION & FEES

Program Title: Vocational Nurse Pre-Reqs Pre-Req Duration Hours: 80 Registration Fee: $ 150.00*

Program Type: Prerequisites Days: 16 Text Books: $ 197.00*

Training Location: Fremont Equipment/Kit/Uniforms: $ 0.00

Pre-Req Start Date: 07/13/2015 Misc Fees: $ 52.50*

Pre-Req End Date: 7/29/2015 Student Tuition Recovery Fund: $ 0.00*

Class Days and Time:1

stweekTuesdayFriday

2nd

weekMondayFriday

3rd

weekMondayFriday

4th

weekMondayTuesday

Training Costs: $ 2,750.50

TOTAL TUITION FOR ENTIRE PROGRAM: $ 3,150.00

TOTAL CHARGES FOR CURRENT PERIOD OF ATTENDANCE: $ 3,150.00

5:30 pm10:30 pm * = NON REFUNDABLE ** = NON REFUNDABLE IF USE

Admissions Representative: Nick Marsh

STUDENT IS RESPONSIBLE FOR TOTAL TUITION INDICATED ABOVE. IF STUDENT RECEIVES A LOAN, STUDENT IS RESPONSIBLE FOR REPAYING THE

LOAN AMOUNT PLUS ANY INTEREST, LESS THE AMOUNT OF ANY REFUND. [ s:a:r ]

Student Signature:

If I fail to repa a federal or state goeret loa or a loa guaratee age loa, ioe ta refud ould e take away, and I would

not be able to get other student financial aid or government housing assistance until I pay off the loan. I am responsible for this amount and if I

cancel my loan without notification, I may be subject to relinquishing my seat. If I get a student loan, I understand I am responsible for repaying

the loa plus iterest.

"Prior to signing this enrollment agreement, you must be given a catalog or brochure and a School Performance Fact Sheet, which you areencouraged to review prior to signing this agreement. These documents contain important policies and performance data for this institution.

This institution is required to have you sign and date the information included in the School Performance Fact Sheet relating to completion

rates, placement rates, license examination passage rates, salaries or ages, ad the ost reet threeear ohort default rate, if appliale,

prior to signing this agreement."

Initials: [ i:a:r ] "I certify that I have received the catalog, School Performance Fact Sheet, and information regarding completion rates,

placement rates, license examination passage rates, salary or wage information, and the most recent three-year cohort default rate, if

applicable, included in the School Performance Fact sheet, and have signed, initialed, and dated the information provided in the School

Performance Fact Sheet."Any questions a student may have regarding this enrollment agreement that have not been satisfactorily answered by

the Unitek College may be directed to the Bureau for Private Postsecondary Education at 2535 Capitol Oaks Drive Suite 400, Sacramento, CA 95833

www.bppe.ca.gov or toll free at (888) 370-7589 or by fax (916) 263-1897. A student or any member of the public may file a complaint about this

Unitek College with the Bureau for Private Postsecondary Education by calling (888) 370-7589 or by completing a complaint form, which can be

otaied o the ueaus Iteet We sitewww.bppe.ca.gov.

All documents referred to in this agreement become an integral part of the complete agreement.

I understand that this is a legally binding contract when signed by the student and accepted by the institution.

I uderstad that this is a legall idig otrat. M sigature elo ertifies that I hae read, uderstood, ad agreed to my rights and

resposiilities, ad that the Uitek Colleges aellatio ad refud poliies hae ee learl eplaied to e.

[ s:a:r ]

[ d:a:r ]

SIGNATURE OF STUDENT DATE SIGNATURE OF PARENT/GUARDIAN DATE

APPROVED BY SCHOOL OFFICIAL:___________________________________________________________ DATE:_______________________ ___

sh

04/15/2015
http://www.unitekcollege.edu/http://www.rightsignature.com/documents/BWZEH8JHR4LUGP2GMEJSFBhttp://www.bppe.ca.gov/http://www.bppe.ca.gov/http://www.bppe.ca.gov/http://www.rightsignature.com/documents/BWZEH8JHR4LUGP2GMEJSFBhttp://www.rightsignature.com/documents/BWZEH8JHR4LUGP2GMEJSFBhttp://www.rightsignature.com/documents/BWZEH8JHR4LUGP2GMEJSFBhttp://www.bppe.ca.gov/http://www.unitekcollege.edu/


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GENERAL TERMS

1. All references to Applicant or Student indicate the individual named on the first page of this Program Enrollment Agreement. The reference to

tudet a also appl to tudets Co-Signer or Parent or Guardian, if applicable, on this Program Enrollment Agreement. This Program

Enrollment Agreement may be referred to as Agreement throughout this contract. Unitek College may be referred to as Unitek College or

School. For this Program Enrollment Agreement, the Program of study indicated on the first page may be referred to as Program or Course.

2.

No applicant shall be discriminated against or rejected from admission to Unitek College on the basis of age, race, color, sex, sexualorientation, disability or national origin. For information regarding Non-Discrimination or to resolve complaints contact the Campus Director.

For the establishment of proper student records, Student gives Unitek College administrative employees permission to view Studets eods

3. Unitek College cannot promise employment or level of income to any student or graduate. Student understands that employer reserve the

right to run background check based on their company policies.

4. Student understands that Unitek College is a private post-seoda shool. Uitek Colleges paet opa, Unitek Information Systems,

owns another training institute called Unitek Education. Unitek Education and its programs are in no way affiliated with Unitek College.

tudet a e otated the Uitek College ai apus i Feot egadig tudets education or employment. Student may also be

otated Uitek Colleges paet opa, Uitek Ifoatio stes, egadig tudets fiaial aout status. Both offices are

located at 4670 Auto Mall Parkway, Fremont, CA 94538. Unitek Information Systems may be reached at 510-249-1060.

5. Once the student has paid all tuition per the tuition payment schedule, books and supplies for the program will be provided by Unitek College

unless Student elects to opt out (see the All-Inclusive Tuition Opt-Out Form included in this Agreement). If the student withdraws, Unitek

College reserves the right to accept or deny returned items based on the condition of the item. Any Lost, damaged or stolen items must beeplaed at tudets epese.

6. Official Transcript, Completion Certificate or Degree, may be issued only after the entire program has been successfully completed and all fees

are paid in full or otherwise accounted for.

7. Clinical Rotation or Externship assignments (if applicable) are the result of collaborative efforts and educational partnership contracts between

external organizations/facilities and Unitek College. The particular organization or facility assigned to Student is subject to change on short

notice, and Clinical Rotations or Externships with any specific organization or facility are not guaranteed in advance. All facilities used for

Vocational Nursing and Registered Nursing Clinical Rotations must be approved by BVNPT and BRN respectively, All Externship

organizations/facilities must be approved by the Director of career services.

8. The start and completion dates of Programs are subject to change, and Unitek College reserves the right to postpone the start of a Program.

In such cases Student will be duly notified and offered the opportunity to consent to the new Program dates. The maximum postponement of

a Program start date is 90 days, beyond which a full refund of all monies paid will be offered.

9.

In the event that Unitek College discontinues a program, a full refund of all monies paid will be given to students who have enrolled but notstarted in the discontinued program.

10. Unitek College reserves the right to change or modify, without notification to Student, the Program content, equipment, staff, materials or

organization. In no event will such changes diminish the quality of the program or result in tuition changes for currently-enrolled students.

11. Uitek College esees the ight to ejet a Appliat ho does ot eet the Poga adissio euieets. tudets erollment may

be teriated at the eletio of the Chief Aadei Offie, Capus Dieto, o Poga Dieto if tudets aadei pogess, ehavior,

asees, o tadiess does ot ofo to Uitek Colleges poliies as stated i the hool Catalog. I suh eet, the etet of tudets

tuitio oligatio ill e i aodae ith Uitek Colleges efud poli, as efeeed i this ageeet.

12. If this Agreement is assigned to a third party, Student will continue to be bound by all the terms and conditions of this Agreement. If this

Agreement is so assigned, any dispute regarding this Agreement must be settled between Student and Unitek College.

13. Student is responsible for payment of any portion of the Total Tuition not covered by a third party. Student is ultimately responsible for

payment of Total Tuition. If any third party defaults or refuses to make payment, Student must immediately pay Unitek College the portion of

Total Tuition due and any additional fees, if incurred. Student must sign and adhere to a separate Retail Agreement for the fulfillment of

tuitio oligatios. etail Ageeets a a Poga ad studets eligiilit fo Fedeal tudet Aid, Piate Loas and other payment

options. The terms of the Retail Agreement are in addition to the terms of this Enrollment Agreement; should there be a conflict between the

terms of the two agreements, the Retail Agreement shall prevail.

14. If any section of this Agreement shall be deemed invalid or unenforceable, it shall not affect the other sections hereof, and this Agreement

shall be construed in all respects as if such invalid or unenforceable section was omitted.

Initials: [ i:a:r

15. This Agreement constitutes the complete and fully integrated contract between Unitek College and Student, and supersedes all previous oral

and written agreements and discussions. This Agreement may be changed only by an agreement in writing between Unitek College and

Student. Student has read and understood this Agreement and has not entered into this Agreement in reliance on any promises made by

Unitek College or any of its representatives or agents.

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Initials: [ i:a:r

16. NOTICE CONCERNING TRANSFERABILITY OF CREDITS AND CREDENTIALS EARNED AT UNITEK COLLEGE:The transferability of credits earned

by Student at Unitek College is at the complete discretion of the institution to which Student may seek transfer to. Acceptance of the

certificate or degree Student earns at Unitek College is also at the complete discretion of the institution to which Student may seek to

transfer. If the credits, certificate or degree that Student earns at Unitek College are not accepted at the institution to which Student may seek

to transfer, Student may be required to repeat some or all of tudets ouseok at that istitutio. Fo this easo tudet should ake

etai that the edits, etifiate o degee assoiated ith tudets hose Poga at Uitek College ill eet tudet s educational

goals. This may include contacting an institution to which Student may seek to transfer after attending Unitek College to determine if

tudets edits ill tasfe.

17. Student understands that California State Law requires Unitek College to document the employment status of graduates, and therefore agrees

to assist Uitek College i otaiig a douetatio o ifoatio euested Uitek College to eif tudets eplo ment status

after graduation for up to 2 years after graduation from Unitek College.

18. Student understands that if tudets hose Poga ith Uitek College that euies a liese i ode to ok i the field, the suh

liesig odies e.g. Califoias Boad of Voatioal Nusig ad Pshiati Tehiias, Boad of Nusig, Phaa Tehician Certification

Board) may require a satisfactory background check in order to apply for or obtain the relevant license. Student understands that a criminal

record may prevent student from getting a license.

19. NOTICE: STUDENT MAY ASSERT AGAINST THE HOLDER OF THE PROMISSORY NOTE STUDENT SIGNED IN ORDER TO FINANCE THE COST OF THE

EDUCATIONAL PROGRAM ALL OF THE CLAIMS AND DEFENSES THAT STUDENT COULD ASSERT AGAINST THIS UNITEK COLLEGE, UP TO THE

AMOUNT STUDENT HAVE ALREADY PAID UNDER THE PROMISSORY NOTE.

20. Student Tuition Recovery Fund

a. You must pay the state-imposed assessment for the Student Tuition Recovery Fund (STRF) if all of the following applies to you:

i. You are a student, who is a California resident and prepays all or part of your tuition either by cash, guaranteed

student loans, or personal loans, and

ii. Your total charges are not paid by any third-party payer such as an employer, government program or other payer

unless you have a separate agreement to repay the third party.

b. You are not eligible for protection from the STRF and you are not required to pay the STRF assessment, if either of the following

applies:

i. You are not a California resident.

ii.

Your total charges are paid by a third party, such as an employer, government program or other payer, and you haveno separate agreement to repay the third party.

The state of Califoia eated the tudet Tuitio eoe Fud TF to eliee o itigate eooi losses suffeed students in

education programs who are California residents, or are enrolled in a residency programs attending certain schools regulated by the

Bureau of Private Postsecondary Education.

You may be eligible for STRF if you are a California resident or are enrolled in a residency program, prepaid tuition, paid the STRF

assessment, and suffered an economic loss as a result of the following:

1. The school closed before the course of the instruction was completed.

2. The shools failue to pa efuds o hages o ehalf of a studet to a thid pat fo liese fees o a othe pupose,or to

provide equipment or materials for which a charge was collected within 180 days before the closure of the school.

3. The shools failue to pa o eiuse loa poeeds ude a fedeall guaateed studet loa poga as euied la or

to pay or reimburse proceeds received by the school prior to closure in excess of tuition and other costs.

4. There was a material failure to comply with the Act of this Division within 30 days before the school closed or, if the material

failure began earlier than 30 days prior to closure, the period determined by the Bureau.

5. An inability after diligent efforts to prosecute, prove, and collect on a judgment against the institution for a violation of the At.

However, no claim can be paid to any student without a social security number or a taxpayer identification number.

Note: Authority cited: Sections 94803, 94877 and 94923, Education Code. Reference: Section 94923, Education Code

21. State of California ApprovalUnitek College's application for approval to operate has ee eieed Califoias Bueau fo Piate Post-

Secondary Education (BPPE) resulting in a full approval which is set to expire on March 18, 2015.

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22. Unitek College purchases books from various vendors, often at volume discounts, and includes them by default within the total fees paid by a

studet. This ethod is alled ilusie tuitio ad edues the ude o studets to fid ad puhase all euied ooks themselves.

Student may opt out of paying inclusive tuition by signing the books waiver form, which will obligate student to acquire all necessary books by

the scheduled first day of class. By opting out of inclusive tuition and agreeing to purchase the required books, the total fees charged to the

student by Unitek College at the time of enrollment will be reduced by the then-current total costs paid by Unitek College to acquire the

books.

23.

ASSIGNMENT OF INTEREST: (To be signed only if agreement is assigned) for valuable consideration, (the receipt and adequacy of which is

hereby acknowledged) Unitek College assigns all of its rights, title and interest in this agreement to: __________________________________

under the terms of the agreement between Unitek College and the assignee.

School official signature:_________________________________ Date:_________Initials: [ i:a:r

24. tudets eollig i Uitek Colleges Voatioal Nusig VN poga a eeie a oe -time $2,000.00 Alumni credit if they later meet the

adissios euieets ad eoll i Uitek Colleges Assoiate Degee of Nusig(ADN) program. This Alumni credit expires eighteen

months after the completion of the VN program. This is a promotional discount offer which cannot be combined with any other discounts and

is only applicable if all aspects of the Vocational Nursing training was taken at Unitek College. Unitek College reserves the right to discontinue

this promotional discount offer.

25. tudets ho ae eollig i Uitek Colleges MA poga a aail of a oe-time $2,500.00 Alumni credit if they later meet the admissions

reuieet ad eoll i the Uitek Colleges VN poga, poided the VN poga is eig offeed. This Alui edit epies one year

after completion of the MA program and may be used with one enrollment only. The promotional discount offer cannot be combined withany other discounts and is only applicable if all aspects of the MA training had been completed at the college. Unitek College reserves the right

to discontinue this promotional discount offer.

26. DISTANCE EDUCATION COURSES*(Applicable only for Distance Education Programs)

a. School shall transmit the any necessary logins and materials to the student between four and seven days after the school

accepts the student for admission.

b. Request of transmittal of materials: (1) School shall transmit all lessons and materials to student if student has fully paid for

program and, after receiving the first lesson and initial materials, requests in writing that all materials be sent; (2) if school

sends balance of materials at students request, school is obligated to provide the other educational services but shall not be

obligated to pay any refund after all lessons/materials are sent.

c. The student will have the right to cancel the agreement and receive a full refund before the first lesson and materials are

received. If the school sent the first lesson and materials before an effective cancellation notice was received, the school shall

make a refund within 45 days after the student's return of the materials unless the student has begun the on-ground portion of

the program.

*Not all programs offer distance education courses

27. By signing this agreement I agree that Unitek College, its affiliates and agents, may send text messages to me. I will not hold Unitek College, its

affiliates or agents liable for any phone charges incurred through calls or the sending / receiving of text messages. I also understand that a

text message may not necessarily be sent for every important event or activity, and may be sent for information on job opportunities,

placement status, or information updates.

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My signature below certifies that I am an authorized representative of Unitek College and that I have personally explained Unitek Colleges

Cancellation & Refund Policies to the student.

Admission Representative (Print Name): Nick Marsh ________________

Admission Representative (Signature): __________ Date:

Approved by School Official (Signature): Date:

I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ABOVE TERMS FOR UNITEK COLLEGE.

[ s:a:r ]

Student Signature: Date: [ d:a:r ]04/15/2015
http://www.unitekcollege.edu/http://www.rightsignature.com/documents/BWZEH8JHR4LUGP2GMEJSFBhttp://www.rightsignature.com/documents/BWZEH8JHR4LUGP2GMEJSFBhttp://www.unitekcollege.edu/


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STUDENTS RIGHT TO CANCEL

1. All monies paid by an applicant must be refunded if requested within three days after signing an enrollment agreement and making an

initial payment.

2. You have the right to cancel your enrollment for a program of instruction, without any penalty or obligations, through attendance at the

first class session or the seventh calendar day after enrollment, whichever is later. After the end of the cancellation period, you also have

the right to stop school at any time; and you have the right to receive a pro rata refund if you have completed 60 percent or less of thescheduled days in the current payment period in your program through the last day of attendance.

3. Cancellation may occur when the student provides a notice of cancellation at the following address: 4670 Auto Mall Parkway, Fremont, CA

94538. This can be done by mail or by hand delivery.

4. The notice of cancellation, if sent by mail, is effective when deposited in the mail properly addressed with proper postage.

5. The notice of cancellation need not take any particular form and, however expressed, it is effective if it shows that the student no longer

wishes to be bound by the Enrollment Agreement.

6. If the Enrollment Agreement is cancelled the school will refund the student any money he/she paid, less a registration or administration

fee not to exceed $150.00, and less any deduction for equipment not returned in good condition, within 45 days after the notice of

cancellation is received.

7. You must exercise your right to cancel by the following date: [ t:a:r ]

TUDENT RIGHT TO REFUND

8. If student is receiving financial aid funds, student is entitled to a refund of moneys not paid from financial aid.

Initials: [ i:a:r sh

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WITHDRAWAL FROM THE PROGRAM

You may withdraw from the school at any time after the cancellation period (described above) and receive a pro rata refund if you have completed

60 percent or less of the scheduled days in the current payment period in your program through the last day of attendance. The refund will be less

a registration or administration fee not to exceed $150.00, and less any deduction for equipment not returned in good condition, within 45 days of

cancellation or withdrawal from program. If the student has completed more than 60% of the period of attendance for which the student was

charged, the tuition is considered earned and the student will receive no refund.

Students can drop classes by contacting the Registrar. Students who drop when enrolled from 0% to 75% of the calendar days of the applicable

seeste, odule o sessio ill eeie a W o thei tasipt. tudets ho dop he eolled past this poit ill eeive a letter grade on

their transcript.

For the purpose of determining date of determination for a refund under this section, a student shall be deemed to have cancelled from a program

of instruction when any of the following occurs:

The studet otifies the istitutio of the studets aellatio o as of the date of the studets ithdaal, hihee is later.

The institution teiates the studets eollet fo failue to aitai satisfato pogess; failue to aide the ules ad

regulations of the institution; absences in excess of maximum set forth by the institution; and/or failure to meet financial obligations to

the School.

The student has failed to attend class for fourteen consecutive scheduled class or clinical days.

Failure to return from a leave of absence.

For determining the amount of the refund, the last date of recorded attendance will be utilized. The amount owed equals the daily charge for the

program (total institutional charge, minus non-refundable fees, divided by the number of days in the program), multiplied by the number of days

attended prior to withdrawal. For the purpose of determining when the refund must be paid, the refund will be issued 45 days from the date of

deteiatio. Fo pogas eod the uet paet peiod, if ou ithda pio to the et paet peiod, all hages collected for the

next period will be refunded.

If the student has received any Federal Title IV financial aid funds, the school is obligated to do an R2T4 even if a credit balance has already been

issued. At the time of enrollment the student must indicate via the Authorization of Credit Balances form what authorization a student is giving

Unitek College as it relates to any excess funds. The choices include the following:

Authorizing Unitek College to retain and apply any credit balance to future charges and send student any credit balance resulting from

excessive funding after tuition has been fully paid. Authoizig Uitek College to etu all edit alae eaiig o studets aout to lede ad ot authoizig Uitek C ollege to

apply any credit balance to future charges. Furthermore, understanding that this option will make student responsible for any debt to

Unitek College.

Authorizing Unitek College to send student all credit balance remaining on their account. Furthermore, understanding that this option

will make student responsible for any debt to Unitek College.

It is the shools esposiilit to do a T ad the shool is oligated to do a T even ifa credit balance was already issued and the school

eeds to get a upaid alae fo studet. Fo pogas eod the uet paet peiod, if ou ithda pio to the et paet

period, all charges collected for the next period will be refunded.

Initials: [ i:a:r sh


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AGREEMENT TO BINDING ARBITRATION AND WAIVER OF JURY TRIAL

I, Sandy Hernandez, agree that any dispute arising from my enrollment at Unitek College, no matter how described, pleaded or styled, shall be

resolved by binding arbitration under the substantive and procedural requirements of the Federal Arbitration Act, by a single arbitrator, conducted

by the Better Business Bureau BBB at thei Oaklad Califoia Offie, ude its ules. All deteiatios as to the sope, efoeailit ad

effect of this arbitration agreement shall be decided by the arbitrator, and not by a court. The award rendered by the arbitrator may be entered in

any court having jurisdiction.TERMS OF ARBITRATION

1. Both Student and Unitek College irrevocably agree that any dispute between them shall be submitted to Arbitration.

2. Neither the Student nor the College shall file or maintain any lawsuit in any court against the other, and agree that any suit filed in

violation of this Agreement shall be dismissed by the court in favor of an arbitration conducted pursuant to this Agreement.

3. The aitatos deisio shall e set foth i itig ad shall set foth the essetial fidigs ad olusios upo hih the decision is

based.

4. Any remedy available from a court under the law shall be available in the arbitration.

PROCEDURE FOR FILING ARBITRATION

Students are strongly encouraged, but not required, to utilize the Grievance Procedure described in the Catalog, prior to filing arbitration.

A student desiring to file arbitration should first contact the Campus Director, who will provide the student with a copy of the BBB Rules. A Studentdesiring to file Arbitration should then contact the Better Business Bureau at Oakland California Office, which will provide the appropriate forms

and detailed instructions. The Student should bring this form to BBB.

A student may, but need not, be represented by an attorney at the Arbitration.

Acknowledgement of Waiver of Jury Trial and Availability of BBB Rules

By my signature below, I acknowledge that I understand that both the College and I are irrevocably waiving rights to a trial by jury, and are selecting

instead to submit any and all claims to the decision of an arbitrator instead of a court. I understand that the award of the arbitrator will be binding,

and not merely advisory.

I also acknowledge that I may at any time, before or after my admission, obtain a copy of the Rules of the Better Business Bureau, at no cost, from

the BBB.

[ s:a:r ]

Student Signature: Date: [ d:a:r ]

School Official Signature:________________________________________________ Date:____________ ____________

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ALL-INCLUSIVE TUITION OPT OUT WAIVER

[c:a:r] I DO NOTwish to opt out of books and supplies. [ s:a:r ]

Sandy Hernandez [ d:a:r Student Name Student Signature Date

If electing to opt out:

I, Sandy Hernandez, have decided that I am opting out of the all- inclusive tuition and wish to make my own arrangements for all required items for

the Licensed Vocational Nursing program.

I acknowledge that is it my responsibility to have the books and/or supplies needed to successfully participate in any class lecture or lab work.

Furthermore, I understand that by opting out of this all inclusive tuition, I am fully responsible in acquiring all the necessary books and supplies

needed to successfully complete the program, as indicated on the attached pages.

SELECT ONE: I wish to opt out of the books and supplies.

I wish to opt out of the books only.

I wish to opt out of the suppliesonly.

Sandy Hernandez

Student Name Student Signature Date

Purchasing Books & Supplies POLICY:

Unitek College purchases Books & Supplies from various vendors, often at volume discounts, and includes them by default

within the total fees paid by a student. This method is called inclusive tuition and reduces the burden on students to find

and purchase all required Books & Supplies themselves. Student may opt out of paying the inclusive tuition, which will

obligate student to acquire all necessary books & supplies by the scheduled first day of class. By opting out of inclusive

tuition and agreeing to purchase the required books & supplies yourself, the total fees charged to student by Unitek College

at the time of enrollment will be reduced by the then-current total costs paid by Unitek to acquire the books and supplies.

Once a student has opted out of books or supplies they cannot opt back in but instead will need to purchase the books

and/or supplies from Student Services.

Received By:

School Official Date

X

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Student Performance Fact Sheet - 2012 & 2013

Program Vocational Nursing Program Length11 Months

Campus: Fremont (Main), San Jose (Branch), Sacramento (Branch)

Completion RatesCompleted in 100%Calendar Year Number of Students Who Began Program

1 Students Available for

Graduation2

Graduates3 Completion Rate

4

2012 166 166 126 50%

2013 342 342 126 37%

Completed in 101% to 150%Calendar Year Number of Students Who Began

Program1

Students Available for

Graduation2

150%

Graduates5

150% Completion

Rate6

2012 73 73 60 25%

2013 342 342 120 39%

Placement RatesStudents are entitled to a list of the job classifications considered to be in the field of this educational program. To obtain this list, please ask an institutional

epesetatie o ou a eie the list of the istitutios esite athttp://www.schoolofchoice.com/jobclassifications.

License Examination Passage Rates (continually administered tests)

The rates are based on students completing the program and taking the NCLEX-PN exam in the year indicated.

Calendar Year # Taking Exam10

# Who Passed First Exam13

# Who Failed First Exam Passage Rates12

2012 - Fremont 91 83 8 91.21

2012 - San Jose 31 25 6 80.65

2012 - Sacramento 45 33 12 73.33

2013 - Fremont 50 42 8 84.00

2013 - San Jose 45 39 6 86.67

2013 -Sacramento 48 41 7 85.42

Salary and Wage InformationCalendar

Year

Grads Avail for

Empl7

Grads Employed in

Field8

Annual Salary & Wages Reported Graduates Employed in the Field14

Less than

$25,001

$25,001-

$30,000

$30,001

-$35,000

Greater

than

$35,000

Student not

Reporting

Salary

2012 165 31 5 4 5 17 0

2013 100 21 4 1 5 11 0

Students are entitled to a list of the objective sources of information used to substantiate the salary disclosure. To obtain this list, please ask an institutional

representative where to view this list.

Calendar

Year

Number of

Students

Who Began

Program1

Number of

Graduates3

Graduates

available for

Employment7

Graduates

Employed in

the Field8

Placement Rate

Employed in

the Field9

Graduates Employed

in the Field less than

32 hrs/wk

Graduates

Employed

the Field a

least 32 hrs/

2012 166 126 103 22 21% 3 19

2013 342 126 100 21 21% 4 17
http://www.unitekcollege.edu/http://www.schoolofchoice.com/jobclassificationshttp://www.schoolofchoice.com/jobclassificationshttp://www.schoolofchoice.com/jobclassificationshttp://www.schoolofchoice.com/jobclassificationshttp://www.unitekcollege.edu/


11/29


12/29





STUDENT EMERGENCY/CONTACT FORM

STUDENT INFORMATION

Name

Sandy Hernandez

Other Names (if any)

[ t:a:o

Street Address

1120 sherman st

City

San Jose

State

CA

Zip

95110

Primary Contact Number

408-781-8420

Secondary Contact Number

[ t:a:o

Email Address:

[email protected]

US Resident Contact

Name

[ t:a:o ]

Relationship

[ t:a:o

Street Address

[ t:a:o ]

City State Zip

[ t:a:o ] [ t:a:o ] [ t:a:o


[ t:a:o ]


[ t:a:o Email Address:

[ t:a:o ]

Medical Emergency Contact

Name

[ t:a:r ]

Relationship

[ t:a:r ]

Street Address

[ t:a:o ]

City State Zip

[ t:a:o ] [ t:a:o ] [ t:a:o


[ t:a:r ]


[ t:a:o

Email Address:

[ t:a:o ]

Program Enrolled In: Vocational Nursing

Program Time:

Evening

Current Mobile Number:

[ t:a:r ]

Service Provider:

[ t:a:r ]

Acknowledgement of mandatory SMS phone number for emergency notifications:

SMS (Short Message Service via mobile text) will be used for emergency notifications. This mandatory campus safety measure requires all activestudents of Unitek College to maintain a valid cell phone number on file.

By signing below I assert that I have provided a current and active mobile phone number on this Emergency Contact form, and I acknowledge my

responsibility to update and maintain a current/active mobile phone number while attending Unitek College.

[ s:a:r ]

Sandy Hernandez [ d:a:r ]


Greg Carbajal boyfriend

1120 Sherman st san jose ca 95110

4083934147

4087818420 verizon

04/15/2015


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(FERPA) STUDENT RECORD RELEASE FORM

Student Name: Hernandez, Sandy,

(Last Name, First Name, M.I.)

Student Number: 209989 Program: VN Pre-Requisite

My records may be released to only the following individuals:

[ t:a:o ] [ t:a:o ]

(Last Name, First Name, M.I.) (Relationship to Student)

[ t:a:o ] [ t:a:o ]


[ t:a:o ] [ t:a:o ]


[ t:a:o ] [ t:a:o ]


[ t:a:o ] [ t:a:o ]


I hereby consent freely and voluntarily to the disclosure, inspection, and copying of information and documents relating to my financial aid,

credentials, qualifications, and performance with Unitek College to the individuals in the above list. This release form shall remain in effect

throughout my enrollment at Unitek College.

[ s:a:r ]

Student Signature: Date: [ d:a:r ]

Registrar

School Official Name Title

School Official Signature Date

04/15/2015


14/29





PROGRAM ENROLLMENT FORM CHECKLIST

I understand the information provided and presented to me in the following documents:

Program Enrollment Agreement

Agreement to Binding Arbitration

All-Inclusive Tuition Opt Out Waiver

Prior to signing this Program Enrollment Agreement, I have reviewed and accepted the following items as part of the Admissions Application:

School Catalog

School Performance Fact Sheet

Background Check Authorization Form

GED/High School Diploma Attestation

Student Emergency Contact Form

Credit Granting Request Form

FERPA Records Release Form

Program Passing Assistance Form

Program Immunization Requirements

Program Physical Examination Form

Before confirming registration, the following items must be submitted to Unitek College:

Proof of High School / GED or Equivalent

Government Issued Valid Photo ID

Admissions Application

I acknowledge receipt of all documents listed above.[ s:a:r ]

Sandy Hernandez [ d:a:r


Nick Marsh

Admissions Rep Name Admissions Rep Signature Date

04/15/2015


15/29





BACKGROUND CHECK AUTHORIZATION FORM

Course: Licensed Vocational Nursing Program Date: _April 14, 2015______

Start Date: _ 07/13/2015______________ Location: _ Fremont __________

I, Sandy Hernandez, authorize Unitek College to perform a complete background investigation for the past 7 years. This

background investigation includes a criminal search and social security trace.

Full Legal Name: [ t:a:r ] [ t:a:o ] [ t:a:r ]First, Middle & Last

Social Security Number: [ t:a:r ][t:a:r][ t:a:r ]

(xxx-xx-xxxx)

Drivers License or State ID Number: [ t:a:r ]

Addresses for last 7 years (please list County):

1. 1120 sherman st, San Jose, CA, 95110,[ t:a:r ]County

(Address, City, State, Zip, County)

2. [ t:a:o ]


3. [ t:a:o ]


Date of Birth: 05/04/1974

(Month/ Day/ Year)

Please list any alias or former names: [ t:a:o ]

Criminal Report: X SST: X

[ s:a:r ]



Sandy Hernandez

545 33 6116

b3352259

usa

1015 Byers st Gilroy, Ca 95020

860 E Central Ave Morgan Hill, Ca 95037

04/15/2015


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EDUCATIONAL REQUIREMENTS - VOCATIONAL NURSING PROGRAM

All students must show proof of their High School Diploma, GED or equivalent in order to complete the enrollment process and be

officially approved to start the program.

Students must provide proof in one of the following formats:

1.

Copy of a United States High School Diploma or Official Transcript from a state approved or United States Department ofEducation approved school.

2. Copy of a GED Certificate

3. Cop of a Assoiates Degee otaied fo a Uited tates Depatet of Eduatio Aedited shool

4. Copy of a Bachelors Degree obtained from a United States Department of Education Accredited school

5. Masters Degree obtained from a United States Department of Education Accredited school

6. A foreign High School Transcript, Associates Degree Transcript, Bachelors Degree Transcript, Masters Degree Transcript that

has been evaluatedto be the equivalent of a United States High School Diploma

Foreign Transcripts - Translation and Evaluation Requirements

For MA, PT and VN Program Applicants: All students providing a foreign proof of education or transcripts for

credit granting must be evaluated by an accepted evaluation service, before completing the enrollment process.Unitek College will only accept evaluations completed by members of the National Association of Credential

Evaluation Services or Academic and Credential Records, Evaluation and Verification Services.

National Association of Credential Evaluation

Services (NACES)

Academic & Credential Records, Evaluation and

Verification Services (ACREVS)

www.naces.org 1776 Clear Lake Avenue, Milpitas, CA 95035

Please visit website for list of approved

services.

Phone: (408) 719-0015 (510) 252-0876

Email: [email protected]

www.acrevs.com

For RN and BSN Students: LVN to RN or RN to BSN applicants wishing to submit their foreign Associates Degree

Tasipt, Bahelos Degee Tasipt, Mastes Degee Tasipts o tasipts fo the euied peeuisites

must have them evaluated by the Commission on Graduate of Foreign Nursing Schools. All foreign transcripts

evaluated by any other evaluation service will not be accepted as part of the enrollment process.

Commission on Graduate of Foreign Nursing Schools (CGFNS)3600 Market Street, Suite 400, Philadelphia, PA 19104-2651(215) 222-8454

www.cfns.org

Student understands and agrees that by signing this acknowledgement that student will submit proof of high school education or

higher evaluated by an approved evaluation service and takes full responsibility to provide the correct proof of documentation

requested. Student also understands that should they not provide satisfactory documentation at the time of application, they may

forfeit the privilege of starting the program, even if student has met all other admissions criteria. Student also understands and

acknowledges that Unitek College will not pay the fees that may be incurred by student in order to submit such proof.

STUDENT ACKNOWLEDGES RECEIPT AND EXPLANATION OF ADMISSIONS CRITERIA OUTLINED ABOVE.

[ s:a:r ]



04/15/2015


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GED/HIGH SCHOOL DIPLOMA ATTESTATION

I, Sandy Hernandez_____, do hereby certify that Icompleted or earned my

(Print Full Name)GED or High School diploma from, _[ t:a:r ]___.

(School Name)

In the state of _[ t:a:r ]_, city of _[ t:a:r ]_.(State) (City)

In the year of_[ t:a:r ]/[ t:a:r ]_.(month/year)

By signing below I certify that the foregoing information is true to the best of my ability and that if the

necessary documentation is not submitted prior to the start date my enrollment may be terminated without

further notice from the school.

[ s:a:r ]



CET

ca Gilroy

July 1993

04/15/2015


18/29





PROGRAM ADMISSION REQUIREMENTS

ADMISSION TO PREREQUISITES PROGRAM

All prospective vocational nursing students shall be chosen without regard to race, color, religion, gender or national origin.

1.

Adissio to Uitek Colleges Voatioal Nusig Poga is ased o ahieig a passig soe i the Wonderlic SLEentrance exam. All prospective students for the Vocational Nursing program are required to take the SLE exam. A satisfactory

score in this test will enable the student to enroll into the pre-requisites course and, upon successful completion, become

eligible for the core program. To be eligible to enroll in the prerequisite program, students must achieve a score of 19 or

higher.

2. Upon successfully passing the SLE exam, students must undergo a personal interview, by appointment, with the Program

Director or Designee (interviews will be scheduled prior to the start of the prerequisites program start). Each student is

required to provide the following documentation prior to the time of the interview:

a. Sealed Official Transcripts for Credit Granting (if official transcripts are not submitted at the time of application,

student forfeits the opportunity to apply for credit granting on courses taken previously).

b. Physical Examination Form and Copies of their immunization and titers.

3.

The following must be complete and submitted prior to attending the prerequisite program:a.

High school diploma or equivalent

b. Copy of Government Issued Photo ID

c. Payment of all fees & tuition.

d. *Physical examination by licensed physician or Advanced Nurse Practitioner establishing sound health (including

immunizations).

*Required by the start of the final week of the prerequisite program.

ADMISSIONS TO CORE PROGRAM

Pre-requisite course must be completed successfully and all criteria for admissions must be met in order to be eligible to be

admitted to the Core programs. Once inducted into the Core program, you will receive an acceptance letter confirming your

admission.

I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THE ABOVE TERMS FOR ADMISSION INTO UNITEK COLLEGE VOCATIONAL

NURSING PROGRAM.

[ s:a:r ]



04/15/2015


19/29





VN CORE SELECTION & ACADEMIC POLICIES

SELECTION INTO VN CORE PROGRAM (UPON SATISFACTORY COMPLETION OF PREREQUISITE)


1.

The students who passed the pre-requisites with the highest grade and who score the highest points in the interview will be

given core seats available. In case two or more students have the same grades in the pre-requisites, points assigned in the

interview will be utilized to make the final student selection for core seats.

2. Students who have successfully completed the pre-requisites but did not receive a core seat in the initial start date, and have

met all of the admission criteria will be assigned core seats in the next available Vocational Nursing program.

ACADEMIC POLICIESReadmission or repeating a course

For any repeated courses, students will be required to pay the training costs associated with the hours the student is repeat ing. For

example, if you fail a course that is 31 hours of instruction in semester 1, but pass all other courses, you will only be required to pay

100% of total cost associated to the 31 hours. You are not required to retake a course that you have successfully completed with an

average of 75% or higher.

1. The Program Director approval is required prior to readmissions.

2. After approval for readmission is received from Program Director, a Change of Status must be processed with Admission

Director, and an updated enrollment agreement must be signed.

3.

Student cannot repeat course until payment has been received by accounting.

4. Students may repeat a course no more than ONEtime (total two attempts). All grades received will appear on the transcript,

and are counted in the cumulative grade point average (GPA).

5. Courses taken at institutions other than Unitek College do not affect the grade point average.

I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THE ABOVE TERMS FOR RE-ADMISSION INTO UNITEK COLLEGE

VOCATIONAL NURSING PROGRAM.[ s:a:r ]



04/15/2015


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SELECTION, ELIGIBILITY AND REGISTRATION - VOCATIONAL NURSING CORE PROGRAM

CORE Eligibility

Students become eligible for enrollment into the LVN CORE program upon passing the Prerequisite program with a grade of 75% or

better.

CORE SelectionAt the conclusion of the Prerequisite program, students eligible for CORE enrollment are selected to receive enrollment priority for

the associated CORE start date and campus. Selection for CORE enrollment priority is based on the grade rankings and interview

points among students from that specific prerequisite program start date.

In cases were two or more students have the same grades in the Prerequisite program, points assigned in the entrance interview wil

be utilized to make the final student selection for CORE.


CORE Registration/Enrollment

Selected students must enroll for the associated CORE start date within three (3) business days following notification of selection. If

a selected student does not enroll for the associated start date within the three-day period, or, if the student provides written

notification to the school that he/she wishes to cancel or postpone enrollet, the studets seat i the assoiated COE stat date

will be made available to the next eligible student.

A student eligible for CORE enrollment but not notified of selection for enrollment into the associated CORE start date will be

assigned a CORE seat in the next available CORE start date at that campus. If a student is selected for CORE enrollment after the

three-day priority enrollment period, and the student chooses to postpone enrollment, the student will not be assigned a seat in the

next CORE start date. The student must wait for enrollment selection following the next Prerequisite program.

Required for CORE Enrollment:

1.

Signed CORE Program Enrollment Form

2. $150 CORE Registration Fee

CORE Postponement

Students eligible for CORE enrollment who wishing to postpone enrollment for the associated CORE start date are advised that theirenrollment for a specific future CORE start date is not guaranteed until the conclusion of the Prerequisite program associated with

the desired CORE start date. At that time, the student will be notified of the seating availability and given the opportunity to enroll.

I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THE ABOVE TERMS FOR RE-ADMIION INTO UNITEK COLLEGE

VOCATIONAL NURSING PROGRAM.

[ s:a:r ]



04/15/2015


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UNITEK COLLEGE PASSING ASSISTANCE

1. Prior to Completion of the VN Program: For students registered in the Vocational Nursing (VN) program, at the end of the

third semester, Unitek College offers an online exam that assists with and predicts the probability of passing the National

Council Licensure Examination for Practical Nurses (NCLEX) national exam.

2. Licensing Application Forms & Fees: Upon successful completion of the Vocational Nursing program, Unitek College will pay

for and facilitate the students with the licensing application process.

3. Please note that you must meet the following criteria before Unitek College can submit your application for licensure:

a.

Completion of all courses with 75% or higher in order to progress to the next semester.

b. Completion of all proctored exams, inclusive ATI Comprehensive VN Exam (ATIPN)

c. Completion of Remediation for all course content exams below a 75%.

d. Copletio of a Copehesie Pedito potoed eit ea ith a % o highe o the Pedited Poailit

of Passing the NCLEX-PN o the Fist Attept. If a soe of % o higher is not achieved on the Comprehensive

Predictor Examination, student will be required to complete a remediation plan/ review of content prior to taking

the exit exam for a second time within 60 days of completing the nursing curriculum. Student is allowed a

maximum of two attempts at the exit exam.

e. Students completing all courses successfully and completing all the required hours, but who have not successfully

passed the ATI exit exam, will be allowed to participate in the pinning ceremony, but will not be allowed to

participate in the graduation ceremony. Students will not receive diplomas or certificate of completion and

submission of student applications for licensure exam will be delayed until all criteria have been met

f. Students in the VN program not successfully achieving a 90% probability score on the second attempt at the ATI

exit exam have not completed the criteria for successful exit from the nursing program; will not receive a diploma

or certificate of completion, and student applications for licensure exam will not be submitted. Students will have

to apply for readmission for the Professional Development course in their last semester and audit all med/surg

courses before attempting retake of exit exam.

4.

Taking the NCLEX Exam: Upon notification from the Board of Nursing that a student is eligible to take the licensing exam,

the student is responsible for registering for the exam. Student can register for this exam online or by mailing in the

application with the feesthe first exam must be taken within 90 days of graduation in order to qualify for the

reimbursement. If the student does not pass the exam on the first attempt, Unitek College will pay for retake of the exam

(the second attempt must be taken 90 days after the first exam but no later than 240 days [8 months] of original graduation

date with the following stipulations:

a. Student must schedule tutoring with Program Director or Assistant Director OR

b. Must show proof of exam preparation through another agency

I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THE ABOVE GUIDELINES AND CRITERIA FOR LICENSING PREPARATION.

[ s:a:r ]



04/15/2015


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IMMUNIZATION REQUIREMENTS - VOCATIONAL NURSING/REGISTERED NURSING

The following are the immunizations required by current clinical facilities. These immunizations assist in decreasing risks and

ensuring student and patient safety.

All students must provide proof of immunization priorto starting the core curriculum and of the Vocational Nursing or RegisteredNursing programs.

I,_Sandy Hernandez_______, will bring in the following documentation to my admissions representative prior to the start of the

core curriculum.

1. Physical Examination form

2.

Positive MUMPS, MEASLES and RUBELLA titer. If negative, 2 MMR vaccinations (given 48 weeks apart), must be followed

by a titer after last vaccination

3. Positive VARICELLA titer. If negative two Varicella immunizations (given 4-8 weeks apart), must be followed by a titer after

last vaccination. A history of chicken pox does notsatisfy this requirement

4. Positive HEPATITIS B surface antibody titer. If negative, three Hepatitis B vaccines completed, must be followed by a titer

after last vaccination

5.

Tdap/DTAP with 10 years6.

Whooping Cough booster if Pertussis missing. Students may sign declination however they must be informed that if required

by clinical facility they may not be placed and may not be able to complete the program.

7. Flu and H1N1 immunization or signed waiver. Student must be advised that if required by clinical facility they may not be able

to be placed, which in turn may result in them not being able to complete the program.

8. TB screen

a. 2 step PPD Skin Test or QuantiFERON Blood test (2 step PPD, 2 separate testsminimum of 10 days and a max of 30

days apart max)

b. If PPD positive, must get a Chest X-Ray; CXR yearly after initial

Student understands , by signing this acknowledgement, student agrees to submit items per description above, and takes full

responsibility to provide proof of a documentation requested. Student understands that should they not provide satisfactory

documentation by the first day of Core, studet ill fofeit the piilege of statig Uitek Colleges Voatioal Nusig/egisteedNursing Programs, even if student has met all other criteria. Student also understands and acknowledges that Unitek College does

not pay the fees that may be incurred in order to submit such proof.

I ACKNOWLEDGE RECEIPT AND EXPLANATION OF THE PREVIOUSLY OUTLINED IMMUNIZATION REQUIREMENTS.

[ s:a:r ]



04/15/2015


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(TO BE COMPLETED AND SUBMITTED BY STUDENT)

PHYSICAL EXAMINATION FORM - VOCATIONAL NURSING / REGISTERED NURSING

Instructions: Please have your physician (MD) or family nurse practitioner (FNP), complete every question. Incomplete forms will

not be accepted.

To the healthcare providers: This form is used to screen for current and potential health risks that may interfere with the

appliats ailit to tai safel i the Liesed Voatioal Nusig Poga. This appliat ill e epeted to stad, sit, and walk

for long periods of time, in addition to physically lifting and transferring 25 to 50 pounds. If you have any doubts about whether this

applicant would be able to meet these requirements, please make a note on the form. Aeptale otatios ilude WNL, OK,

o EE BELOW.

Full Name Date of Birth: Sex:

Male Female

Height Weight Temperature Pulse B/P

Hearing Lungs Resp Ears

R L

Teeth Glands Skin Spine Neuro

Extremities Vessels Abdomen Pelvis

Inguinal Rings Breasts Menstrual Hx Pregnant

Ae thee a eotioal o etal health osideatios that ould ipat tudets ailit to pefo the ole of a liesedvocational

nurse? No Yes (please explain)

Have any allergies? No Yes (please explain)

TB skin test #1 & 2 (two-step), if positive, must have chest x-ray: Results:

This applicant is free of communicable disease? Yes No (please explain)

Additional comments or remarks:

Printed Name: Date:

Authorized Signature: Title:

Student Name: Sandy Hernandez Student Initials: [ i:a:r ] Date:_[ d:a:r ]__sh 04/15/2015


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(STUDENT COPY) TB ANNUAL SYMPTOM REVIEW

(Required for everyone regardless of outcome)

Student Name: Sandy Hernandez ________ Date: April 14, 2015

Date of Birth:__05/04/1974_ Last 4 of Social Security #:_[ t:a:r ] Program: Licensed Vocational Nursing

This questionnaire is required for all students and faculty as part of their annual TB screening. Please note if further follow-up is

required, your healthcare provider must specify the plan of care below (Part 2). You should keep a copy for your files at home.

PART 1: (Please complete prior to seeing Health Care Provider)

TB Symptoms Review

1. Are you currently exhibiting any of the following

symptoms of tuberculosis?

Have you had any of the following within the last 12 months?

Yes No Cough lasting longer than 3 weeks Yes No

Yes No Coughing up blood Yes No

Yes No Fever Yes No

Yes No Weight loss Yes No

Yes No Night sweats Yes No

If the ase is Yes to a of the sptos listed aoe, please state he sptos fist ega; ho log sptos

have occurred; and if patient has been evaluated by physician for symptoms.

2. Yes No Is any person living in your household exhibiting any symptoms of tuberculosis that are listed above? If

the liet aseed Yes, please list the sptos.

3.

Yes No Have you ever has a chest x-ray done to rule out tuberculosis? If the client answeed Yes, please state

when the chest x-ray was done; the name of the physician; and the address and phone number of the physicians/agencywhere it was done.

4. Yes No Have you ever received medication for active tuberculosis disease or preventive treatment for TB

ifetio? If the liet aseed Yes, please state ae of ediatios; he the ediatio as stated ad opleted.

Student Signature Date

Part 2 (Completed by Physician or Nurse Practitioner):

Printed/Typed Name of Health Provider (or legible stamp), indicating name/title:

Health Care Agency affiliation: (city/state)

By signing this form I attest that the symptoms were reviewed. If further action is required I have so noted.

Signature of Health Care Physician/Nurse Practitioner: Date

Any further follow-up, other than annual review questionnaire, in 12 months

6116


25/29





CREDIT GRANTING REQUEST FORM (SCHOOL OF NURSING AND ALLIED HEALTH)

Note: All Veterans must submit all transcripts for review.

Guidelines and Requirements:

1.

Academic credit earned for courses appearing on an official transcript from a regionally or nationally accreditedetifiate/degee gatig shool, ollege o uiesit ith a iiu gade of C . o a . sale ill e ealuated

according to Unitek College policies and subject to approval by the Program Director.

2.

Credit may be given for related previous education from an accredited institution completed within the last five (5)years.

3. Transfer credits based on a different unit of credit than the one prescribed by Unitek College are subject to conversion before

being transferred. Credit granting for paired courses must meet the requirements for both courses.

4. Course evaluations based on official transcripts by the Program Director are final. Any preliminary reviews by campus

personnel are unofficial and not binding, and subject to change.

5. The maximum of credit allowed towards any CORE program is 30% of total program units/hours. Students must complete

70% of the program at Unitek College to be awarded a certificate of completion or degree.

6. A maximum of 12 credits may also be awarded for successful completion of exams from approved national testing programs

(Advanced Placement Exams [AP], College Level Examination Program [CLEP], DANTES[DSST]), according to Unitek College

policy.

7.

Credit may be granted for the following:

a. Successful completion of vocational/practical nursing courses.

b.

Successful completion of registered nursing courses.

c. Successful completion of armed services nursing courses.

d. Successful completion of other courses that are equivalent to courses in the program as determined by the director

of the program.

8. No credit shall be granted for partial courses. Students may also be requested to provide a detailed and official course

description; this can be obtained from the programs catalogue in most cases. Credit may be granted for clinical skills based on

competency check.

Grades and Auditing Following Credit Granting:

1. Grade for courses edited, egadless of gade ahieed fo edited ouseok, ill e a CG to eflet edit gated.

This will not be counted toward GPA.2. Students are permitted and encouraged to audit courses credited. In some cases, students may be required to audit (attend

all class sessions).

Submission Instructions & Deadline:Official sealed transcripts must be submitted to the Registrar/Program Director for

review before the end of the first week of the prerequisite program.

Please mark the appropriate statement with a check mark to indicate appropriate request.

Regular Students

1. I am submitting evaluation request for transfer of credit for courses completed.

2. [c:a:r]I waive credit granting and will attend all portions of the program.

Veteran Students

1. _____ I understand as a veteran I must, and I am, submitting all prior education and experience for evaluation for credit

granting.

Pited Nae_______________________________________________ Vetea: Yes No

Program Director Initials: ____________________ Student Initials: [ i:a:r ]

X

sh


26/29





REFER A COLLEAGUE, FRIEND OR FAMILY MEMBER

Congratulations on your provisional acceptance into Unitek College! Here is your chance to help someone close to you

take the next step forward. Many of our most successful graduates would not have known about Unitek College without

the help of a friend or loved one.

List the name and phone number of the people you wish to help, and your Admissions Representatives will help them

get started!

Name:_ [ t:a:o ]_ Phone:_[ t:a:o ]_




Student Name (Please print):_Sandy Hernandez____Date:__[ d:a:r ]__

Admissions Representative Name: _ Nick Marsh __________________________________

04/15/2015


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BOOK AND SUPPLY LIST - VOCATIONAL NURSING PREREQ & CORE

VN Prerequisite Book Description Edition ISBNs

Medical Terminology for Health Professions (Ehrlich) 7th 978-1-133-71666-2

Dosage Calculations (Pickar) 9th 978-1-111-31959-5

VN CORE Book Description Edition ISBNs

Pharmacological Aspects of Nursing Care (Broyles) 8th 978-1-111-31935-9

Foundations of Nursing Textbook (Christensen) 6th 978-032-305-7325

Foundations of Adult Health Nursing Textbook (Christensen) 6th 978-032-305-7363

Foundations of Nursing Study Guide (Christensen) 6th 978-032-305-7356

Foundations of Adult Health Nursing Study Guide (Christensen) 6th 978-032-305-7394

Mosby's Diagnostic and Laboratory Test Reference (Pagana) 11th 978-032-308-4680

Saunder's Comprehensive Review for NCLEX-PN (Silvestri) 5th 978-145-570-3791

Mosby's Nursing PDQ for LPN (Mosby) 3rd 978-032-308-4475

Mosby's Drug Guide (Skidmore-Roth) 10th 978-032-308-6431

Mosby's Dictionary of Medicine (Mosby) 9th 978-032-307-4032BLS for Healthcare Provider Manual with CD N/A 90-1038

Supplies Description

Medical Supply Kit

For the most current book listings by program section please visit:

http://www.unitekcollege.edu/programs/vocational-nurse/book-list

Book and supply listings may also be obtained from the Unitek College Student Services Department.

Acknowledgement of changes to book and supply listings for students electing to opt-out of all-inclusive program

tuition:

Changes to book listings, including, but not limited to, changes to required edition numbers, publishers, authors or titles,

may occur as necessary. These changes may be made at any time prior to the start of the program. Students electing to

opt-out of all ilusie tuitio fo ooks ad supplies ae esposile fo esuig that all ooks ad supplies

purchased match the most current required book and supply listings.

By signing below I certify that I understand the above policy for book and/or supply purchasing if I elect to opt of all-

inclusive tuition.

[ s:a:r ]



04/15/2015
http://www.unitekcollege.edu/http://www.unitekcollege.edu/programs/vocational-nurse/book-listhttp://www.unitekcollege.edu/programs/vocational-nurse/book-listhttp://www.rightsignature.com/documents/BWZEH8JHR4LUGP2GMEJSFBhttp://www.rightsignature.com/documents/BWZEH8JHR4LUGP2GMEJSFBhttp://www.unitekcollege.edu/programs/vocational-nurse/book-listhttp://www.unitekcollege.edu/


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ENROLLMENT SUBMISSION CHECKLIST: VOCATIONAL NURSING PREREQUISITE

INTERNAL USE ONLY

Student Name: Sandy HernandezFirst Middle Last

Start Date: 07/13/2015 Campus:Fremont Rep Name: Nick Marsh

Agency:

Rep Initials # Document Name Comment

1. COPY - Enrollment Agreement First Page

2. Enrollment Agreement

Disclosures/Application Forms

3. BACKGROUND CHECK AUTHORIZATION FORM

4. EDUCATIONAL REQUIREMENTS

5. CORE SELECTION, ELIGIBILITY AND REGISTRATION

6. GED/High School Diploma Attestation

7. ADMISSION REQUIREMENTS

8. VN CORE ADMISSIONS & ACADEMIC POLICIES

9. PASSING ASSISTANCE

10. IMMUNIZATION REQUIREMENTS - VN/RN

11. PHYSICAL EXAMIINATION FORM - VN/RN

12. Credit Granting Request Disclosure

13. Credit Granting Request Submission Form

14. STUDENT EMERGENCY/CONTACT FORM

15. FERPA/STUDENT RECORD RELEASE FORM

16. Referral Form

17. Book/Supply Listing (Opt-out Acknowledgment)

Required Submissions

18. Assessment Proctor Score Sheet

19. Photo ID (COPY)

20. POG - HS Diploma/GED Proof of Graduation

21. $150 Reg Fee Receipt Agency Student Reg Fee + Books charged to agency student. All other prereq charges credited.

_____________________________________ _____________

Admissions Representative Signature Date

_____________________________________ _____________

School Official Signature Date


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BWZEH8JHR4LUGP2GMEJSFB

Sandy Hernandez

Party ID: 6YGS8MJJXK4IDZBK3DYP8FIP Address: 70.197.19.46

VERIFIED EMAIL: [email protected]

Multi-FactorDigital Fingerprint Checksum 0e9a8f00b5fe4a22de5818783112056d356065e5

Timestamp Audit

2015-04-15 10:50:26 -0700 All parties have signed document. Signed copies sent to: Nick marsh, Sandy

Hernandez, and Nick Marsh.

2015-04-15 10:50:25 -0700 Document signed by Sandy Hernandez ([email protected]) with drawnsignature. - 146.74.216.98

2015-04-14 20:57:19 -0700 Document viewed by Sandy Hernandez ([email protected]). -

70.197.19.46

2015-04-14 14:29:45 -0700 Document created via the RightSignature API by Nick Marsh

([email protected]). - 40.129.185.4

Documents

7-13_Sandy_Hernandez-signed.pdf