Complete each item below and submit application by deadline specified for semester you which to re-enter. Email Address for receipt of confirmation must be accurate and current! Last Name * Enter Last Name First Name * Enter First Name SVCC Student ID# (7- digit number) Street Address Mailing Address if Different from Above City, State, and Zip Code VCCS Student Email Home Phone Enter area code and number or "none" if applicable. Mobile Phone Enter area code and number or "none" if applicable. Campus at which you wish to re-enter the Practical Nursing Program Alberta South Boston Semester to which you are re-applying First semester (PNE 161) Second semester (PNE 162 and/or 173) Third semester (PNE 163 and/or 145) Previous Program Attended Enter the campus where you attended your previous PN Clinical program. What semester and year were you last enrolled in the PN program at SVCC? Please be aware that to be considered for re-entry, you must apply for the next time the class or classes you need are offered. If you wait more than one program cycle, you must apply to start over at the beginning of the program and must meet current requirements. Why did you leave the program or class? How have you grown since leaving or what do you think will make you successful if you are able to continue? If there were issues in clinical, please describe them and how you will overcome them if accepted. Current Cumulative GPA Check to acknowledge that you have read and understand the following. I understand the Program Continuation Policies as listed in the Southside Virginia Community College Nursing Program Student Policies & understand that my grade of “W”, “D” or “F” in a nursing course now causes the loss of any upcoming course space for which I had been pre-assigned. I understand that I will be placed on a list for the next available clinical course I need as of the date of this form & will receive a space if one becomes available prior to the start of the semester. Current or new students have priority over reentry students for available spaces in nursing courses.I understand that I will be contacted by the Nursing Department if a space becomes available. I understand that if space does not become open for the next available course I need, to enter again I must apply for a future program to start again in the first clinical semester, and meet all current requirements at that time in order to apply. Southside Virginia Community College does not discriminate on the basis of race, color, national origin, sex, or disability in its programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policy: Shannon Feinman, Interim Vice-President for Finance and Administration; SVCC, 109 Campus Drive, Alberta, VA 23821; Telephone 434-949-1005; email firstname.lastname@example.org. I understand that I must enter a valid email address below and I agree to contact SVCC's Health Science counselor at email@example.com promptly if I do not receive a confirmation email verifying receipt of this application. Your E-Mail Address Enter the email address where you would like to receive your "Receipt of Application" confirmation.