ࡱ> 372c bjbj 4 ObOb!PPPPPddd8$d)++++++$R!OPOPPdFPP))i`Y*^5z0=,![!i!PiOO!B : EVERGREEN VALLEY COLLEGE REQUEST TO RETURN TO NURSING PROGRAM FORM Return this form to the Nursing Office, Room S207 No Later Than April 1st for Fall Semester and November 1st for Spring Semester Date: _________________________ Student ID number: __________________________ Last Name: __________________________ First Name: ________________________________ Email Address: _______________________________________________________________________ Telephone: Home: _________________ Cell: ____________________ Business: _______________ Last Semester Enrolled in Nursing Courses: Semester ________ Year ________ Course _________ Name of last Clinical Nursing Instructor: __________________________________________________ Reason for Leaving the Program: ( Military Duty ( Medical/Personal Leave ( Course Withdrawal ( Course Failure: ___ Theory ___ Clinical ( Other (explain below) ______________________________________________________________________________ ______________________________________________________________________________ Indicate the Semester you would like to return: Fall ____ Spring ____ Year _______ Statement: I feel I will be successful in completing the Nursing Program for the following reasons Please write a response to the above statement and include activities completed that were recommended by your instructor and other appropriate activities that will enhance your future success. Please give us detailed information and attach documents if applicable. Submit the following items to the Nursing Office by April 1st for Fall Semester and November 1st for Spring Semester: Completed Request to Return to Nursing Program Form Copy of the letter your instructor gave you when you left the program Written detailed response to above statement (your explanation of remediation you have completed and explanation of why you feel you will be successful at this time) Attach any additional information or documents to support your remediation success such as transcripts from classes taken, etc. Signature: _________________________________________ Date: __________________     Revised: 12/13/19 =BCD\juwy " # + N O o s y {     . / 2 B N ] ^ ` a o t ¸ʳ¸寫寧寫嫧姫姣寫姫ΧΧΧΧΧhY'h-hg'h5^ hOpr>*he5hT>*H*he5hT>*hThe5hr1thh hThTh^mhZ hTh^mhTh^m5CJ\@CDw# $ | } 3 4   k l gd5^$a$$a$     1 2 3 P Q R l m  U [ ] m  # $ * 6 B \ ÿÿzzh6B*phhhwT6B*phhB*phhhB*phhh^mB*phh|!B*phh^mB*phhY'hh@h@CJaJh@CJaJ j0h@h#wh@ j0he5he5h-h^mhg'0 \ ] $ ) 34%KLMgd,gdp=I & Fgd|! & FgdZ gdZ $a$gd,$a$gd\ ^ 234ehoq̾{qf_qfqWJ* hOpr5>*h|!hp=I5>*H*h|!hp=I5>*h|!hp=I5>*B*phh|!hZ 5>*B*phhhwT5B*phhh^m6B*phhh,6B*phhh6>*B*phhh6B*phhhp=I6B*phhh6B*phhhwT6B*ph$%4Tgr|JKMŸŸҮܡ暓wswswswsk`\shhC~3h,CJaJhOprCJaJhW jhW Uhh^m5:EHOJQJhaM hh^m hhhh|!5B*phhZ 5B*phhh(%5B*phhhwT5B*phhaM5B*phh|!5B*phh|!h|!5B*phhhp=I5B*ph$gdp=Igd,21h:pwT/ =!"#$% s666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH >@>  Heading 1$@& 5CJ \DA D Default Paragraph FontViV 0 Table Normal :V 44 la (k ( 0No List HH H0 Balloon TextCJOJQJ^JaJN/N H0Balloon Text CharCJOJQJ^JaJ44 ,0Header  H$6/!6 ,0 Header CharCJaJ4 @24 ,0Footer  H$6/A6 ,0 Footer CharCJaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<   # \    8@0(  B S  ?33QTJJbYh ^`hH.h ^`hH.h pL^p`LhH.h @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PL^P`LhH.bY         %$e5S H|!Z (%g'2q3C~3p=I$LaMwTg3YDb^mOprr1t~&|Bl `@ z,5^#w-Y'}TW @@UnknownG.[x Times New Roman5Symbol3. .[x Arial?Wingdings 29Perpetua5. .[`)TahomaA$BCambria Math"hj|j|T"'IXIX!203QHP $PH2!xxs] (Request to Return to EVC Nursing ProgramEvergreen Valley CollegeLong, Brittany A. 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