School Nurse Certification Application

Name(Required)

First Name Middle Initial Last Name

Phone(Required)

Phone Type(Required)

Social Security Number(Required)

Date of Birth(Required)

Gender(Required)

Address(Required)

Street Address City State ZIP Code

County(Required)

Email Address(Required)

What high school did you graduate from?

Name of School(Required)

Year(Required)

Prior College(s)

Did you graduate from college?(Required)

College Name(Required)

College Graduation Year(Required)

Ethnicity(Required)

African American

American Indian or Alaskan Native

Asian

White

Native Hawaiian or Other Pacific Islander

Are you Hispanic/Latino?(Required)

Yes

Are you a first generation college student (your parent(s)/guardian(s) did not attend college)?(Required)

Yes

Do you have a family member who attended or graduated from Bluefield State University?(Required)

Yes

Relationship

Year Graduated

Semester wanting to attend(Required)

Course(s) in which you wish to enroll(Required)

CRN#

Class

Disclosures

*By providing your cell phone number, you agree to receive text-based communication from Bluefield State University and from the West Virginia Higher Education Policy Commission and the West Virginia Council for Community and Technical College Education, otherwise known as the College Foundation of West Virginia (CFWV). You may also opt-out at any time by replying to any text sent.

Disclosures(Required)

Yes

Initial(Required)

I declare that the information I have supplied on this application is complete, truthful, and correct and authorize BSU to verify the information given on this application.

Signature(Required)

What high school did you graduate from?

Disclosures

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