UPDATED NOTICE - SEIU Local 1000

ttee for LVN to RN Apprenticeship Program at SCCP.O. Box 588500Elk Grove, CA 95758

Save AsRESETPRINTCCHCS LVN TO RN APPRENTICESHIP PROGRAMAPPLICATIONGuidelinesTo apply for the CCHCS LVN to RN Apprenticeship Program, please complete the application and attach the followingdocuments:1.2.3.4.5.Authorization to Obtain Prior Employment Information & Review Personnel folderLVN to RN Prerequisite Courses and Test of Essential Academic Skills (TEAS) Checklist FormCopy of TEAS score report, if TEAS has been completed.Copy of unofficial transcriptsWritten Statement of InterestEmployee InformationNAME (FIRST MI LAST NAME)MAILING ADDRESSLAST FOUR OF SSNCITYSTATEEMAILHOME/CELL NUMBERINSTITUTIONWORK PHONE NUMBERZIP CODEEXTENSIONEmployment HistoryFROM DATETO DATE# OF HOURS PER WEEKNAMEEMAIL ADDRESSTITLE AND/OR JOB CLASSIFICATIONORGANIZATION AND/OR INSTITUTION NAMESUPERVISOR INFORMATIONPHONE NUMBEREXTENSION

Employment History (Cont.)FROM DATETO DATETITLE AND/OR JOB CLASSIFICATION# OF HOURS PER WEEKORGANIZATION AND/OR INSTITUTION NAMESUPERVISOR INFORMATIONNAMEPHONE NUMBEREXTENSIONEMAIL ADDRESSFROM DATETO DATETITLE AND/OR JOB CLASSIFICATION# OF HOURS PER WEEKORGANIZATION AND/OR INSTITUTION NAMESUPERVISOR INFORMATIONNAMEPHONE NUMBEREXTENSIONEMAIL ADDRESSFROM DATETO DATETITLE AND/OR JOB CLASSIFICATION# OF HOURS PER WEEKORGANIZATION AND/OR INSTITUTION NAMESUPERVISOR INFORMATIONNAMEPHONE NUMBEREXTENSIONEMAIL ADDRESSHuman Resources Use OnlyDATE RECEIVEDREVIEWED BYCCHCS LVN TO RN APPRENTICESHIP APPLICATION2

Authorization to Obtain Prior Employment InformationAnd Review Personnel FileI,, (print name) authorize the release of information to arepresentative of the California Correctional Health Care Services (CCHCS).I understand this authorization for release of information includes the review of my official personnelrecords and input from current/former supervisors regarding my employment history, performanceevaluations, probationary reports, attendance, commendations, and disciplinary actions.Any restrictions regarding the release of information are indicated below.This information is considered confidential and shall be treated accordingly by CCHCS.This authorization is valid for one hundred and twenty (120) days.Applicant’s signatureRESTRICTIONDate

CCHCS LVN to RN Apprenticeship Expansion ProgramPrerequisite Courses and TEAS FormPlease thoroughly complete this form identifying all RN prerequisite coursework you are currently takingor have previously completed.Please note that all applicants must also submit unofficial copies of their college transcripts with theirapplication (a computer printout of your records will also suffice). These transcript copies shouldvalidate completion of any prerequisites. Coursework that is “in progress” should also be identified. Ifthe coursework was not completed at Sacramento City College (SCC), it must have been successfullycompleted at an accredited college, transferrable to SCC, and equivalent to the coursework below. (Youmay consult the SCC catalog to review course descriptions: https://www.scc.losrios.edu/catalog/.)Name:SCC PrerequisiteBIOL 430:Anatomy and PhysiologyBIOL 431:Anatomy and PhysiologyBIOL 440:General MicrobiologyOne of:1. ENGWR 300College Composition2. ENGWR 488Honors CollegeComposition and ResearchOne of:1. COMM 301Introduction to PublicSpeaking2. COMM 331Group DiscussionDate:Equivalent Course TitleCollegeGradeCompletionDate(Month/Year)

Prerequisite Courses and TEAS Form (cont.)Name:SCC PrerequisiteDate:Equivalent Course TitleCollegeGradeCompletionDate(Month/Year)One of:1. PSYCH 300General Principles2. PSYCH 480Honors General PrinciplesOne of:1. ANTH 310Cultural Anthropology2. ANTH 481Honors CulturalAnthropology3. SOC 321Race, Ethnicity, andInequality in the US4. SOC 482Sociology of Race,Ethnicity, and Inequality inthe US, HonorsTEAS ExamIf you have t

2. LVN to RN Prerequisite Courses and Test of Essential Academic Skills (TEAS) Checklist Form 3. Copy of TEAS score report , if TEAS has been completed. 4. Copy of unofficial tran