MEDICAL ASSISTANT APPLICATION

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1 PERSONAL INFORMATION Merritt College For Spring 2015 Cohort MEDICAL ASSISTANT APPLICATION Last Name: First Name: MI: Address: City, State, Zip Primary Phone: Additional Phone: Gender: q Female q Male Social Security Number Peralta Student ID# Date of Birth: Country of Birth: Eligible to work in the U.S. q Yes q No Race: q Asian Indian q Cambodian q Chinese q Filipino q Guamanian q Vietnamese q Laotian q Korean q Samoan q Other Asian q Other Asian/Pacific Island q American Indian/Alaskan Native q Black- Not Hispanic q Hispanic q White- Not Hispanic English Language: q Speak q Read q Write q Understand q Some Understanding Native Language (other than English) : q Spanish q Cambodian q Mien q Laotian q Chinese q Vietnamese q Tigrigna q Amharic q Other q Speak q Understand q Read q Write Do you require accommodation for a disability? q YES q NO Describe: Military Status: Veteran: q Yes q No Disabled Veteran: q Yes q Yes, Special Disabled q No

2 EDUCATION INFORMATION (U.S.A. and International) Highest grade completed in school: (please circle one) High School Diploma GED Some College Associate Degree Bachelor s Degree Do you have vocational training? q Yes q No If yes, please explain: Are you currently attending school or training NOW? q Yes q No What are you taking? Where? Have you taken Peralta s English and Math Assessment Test? q Yes q No Which math and/or English courses did you place into? ACADEMIC READINESS Please list any courses that you feel have prepared you for the Medical Assisting programs. Include any coursework and/or training in Medical Terminology, Phlebotomy, Administrative Medical Assisting, Certified Nurse Assistant, or any other health related courses or training. (Please be sure to attach a copy of your transcripts and/or certificates) Course/Training Grade Institution Semester

3 Why are you applying to the Medical Assistant Program? Do you have healthcare experience or training? What are your skills? If you are not admitted to the Medical Assistant Program, what is your second occupation choice? Why? EMPLOYMENT / VOLUNTEER HISTORY (U.S.A. and International)

4 Most Recent Job Company Name Dates to Street Address City State ZIP Country Phone( ) Job Title: Duties: Salary per hour Hours per week Reason For Leaving Company Name Dates to Street Address City State ZIP Country Phone( ) Job Title: Duties: Salary per hour Hours per week Reason for Leaving Company Name Dates to Street Address City State ZIP Country Phone( ) Job Title: Duties: Salary per hour Hours per week Reason for Leaving FERPA Release Form

5 Student Authorization for Release of Information Medical Assisting Program I hereby authorize Merritt College, a participating educator for the Medical Assisting Training Program, to release to the Unity Council and my externship site, non directory information including my grades, transcripts, and other academic information during my participation in the Medical Assisting Training Program. I understand that Merritt College will provide the Unity Council with other information related to academic performance including withdrawal and/or termination from the Medical Assisting Program. I further understand that any demographic information, i.e. age, race/ethnic heritage, gender, etc. that Merritt College provides to The Unity Council will be in aggregate form that does not identify any specific students on the Medical Assisting Program. Name (Please Print) Signature Social Security Number - - Date FERPA Overview

6 The Family Education Rights and Privacy Act of 1974, commonly known as FERPA, is a federal law that protects the privacy of student education records. Students have specific, protected rights regarding the release of such records and FERPA requires that institutions adhere strictly to these guidelines. FERPA gives students the following rights regarding educational records: The right to access educational records kept by the school The right to demand educational records be disclosed, only with student consent The right to amend educational records The right to file complaints against the school for disclosing educational records in violation of FERPA. There are two types of educational records as defined under FERPA. Each type has different disclosure protection: Directory Information A college or university may disclose this type of information without the written consent of the student. The student can exercise the option to restrict the release of directory information by submitting a formal request to the school to limit disclosure. Directory Information may include: 1. Name 2. Address 3. Phone number and address 4. Dates of attendance 5. Degree(s) awarded 6. Enrollment status 7. Major field of study Non- Directory Information this is any information not considered Directory information. This information cannot be released to anyone without the prior written consent. Non- directory information may include: 1. Social Security Numbers 2. Student academic information 3. Race, ethnicity, and/or nationality 4. Gender 5. Transcripts; grade reports In addition you will be required to authorize the release of certain demographic data (age, gender, race, etc.) to The Unity Council. This information will be aggregated and used in the strictest of confidence, for program performance evaluation and statistical purposes only. Thank you in advance for your assistance.

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