WASHBURN INSTITUTE OF TECHNOLOGY Surgical Technology Application for Admission

Transcription

1 WASHBURN INSTITUTE OF TECHNOLOGY Surgical Technology Application for Admission Washburn Institute of Technology Surgical Technology Program 5724 SW Huntoon Topeka KS Fax Date: Fall Semester (August) (yr) DEMOGRAPHIC INFORMATION Name Last Name First Name MI Previous name(s) used Male Female Date of Birth / / Social Security Number - - Permanent Address Number and Street Name City State Zip code Current Address (if different) Number and Street Name City State Zip code Phone ( ) - Work Phone ( ) - Cell Phone ( ) - Alternate contact persons: Name Address Phone RESIDENCY INFORMATION Are you a citizen of the United States of America? Yes No If not, are you on a V1 VISA? Yes No EDUCATIONAL INFORMATION List below all high schools, colleges, universities, nursing schools, or other schools attended. Name of high school, college, or other school City and State Attendance Dates Hours, Degree or Diploma Please request official transcripts, from all high school, G.E.D., colleges, universities nursing schools and other schools previously attended, to be sent to Health Occupations, Washburn Institute of Technology, 5724 SW Huntoon, Topeka, Kan

2 CERTIFICATES Type Certification number Date Received Active or Inactive WORK HISTORY List all past employment. Start with the most current. Employer Name & Address Type of Work Employment Dates Reason for Leaving Thank you for your interest in the Surgical Technology Program at Washburn Institute of Technology. Please complete and submit this application for admission with the $25.00 application fee. Please note all application materials must be received in the Health Occupations Department by April 15 th to be considered for admission. Washburn University prohibits discrimination on the basis of race, color, sex, religion, age, national origin, ancestry, disability, marital or parental status, sexual orientation/gender identity, genetic information, or other non-merit reasons, in University programs and activities, admissions, educational programs or activities, and employment, as required by applicable laws and regulations. The following person has been designated to handle inquiries regarding the nondiscrimination policies: Dr. Pamela Foster, Equal Opportunity Director, Washburn University, 1700 SW College Ave, Topeka, Kansas 66621, , THIS SECTION TO BE COMPLETED IN THE PRESENCE OF A NOTARY PUBLIC: (WIT has a Notary on staff.) State of County of Being duly sworn, I state that the foregoing statements in this application are true and accurate. I am aware that any false, misleading or incomplete statements made on this application could be grounds for non-admission to, or later dismissal from, the surgical technology program at Washburn Institute of Technology. Signed Date Subscribed and sworn to before me this day of 20 Notary Public (seal) Date of Expiration

3 WRITTEN INTERVIEW QUESTIONS Dear Applicant: This written interview is part of the surgical technology application. It must be completed and returned to the Health Occupations secretary along with your application and fee. If necessary, you may use extra paper. 1. What influenced your decision to apply to the Washburn Institute of Technology Surgical Technology Program? 2. Describe your understanding of the role of a Surgical Technician. 3. What participation in personal, school, community or work activities have you had which demonstrate leadership ability? Briefly discuss the importance to you of these experiences. 4. What strengths do you have that will allow you to be a valuable member of the operating room team? And what weaknesses do you have that you would like to work on and improve on to make yourself a valuable member of the OR team? 5. How do you plan on handling any work commitments you may have as well as meeting the demands of the Surgical Technology Program?

4 6. How do you feel about starting your day at 5:30 am? 7. Describe an ideal employee. 8. How do you handle constructive criticism? 9. Do you have a dependence on alcohol or drugs? If yes, please explain. 10. Are you currently participating in a treatment program for drug or alcohol dependence? If yes, please describe. 11. Have you ever been convicted of a crime other that traffic violations? If yes, please explain. 12. Is there anything in your academic record which needs explaining, i.e., incompletes, withdrawals, poor semester, pass/fail scores? 13. Is there anything in your work history that needs explaining, i.e., short lengths of employment, several employment changes within a short period of time?

5 14. Where do you see yourself in 5 years? THIS SECTION TO BE COMPLETED IN THE PRESENCE OF A NOTARY PUBLIC: (WIT has a Notary on staff.) State of County of Being duly sworn, I state that the foregoing statements in this application are true and accurate. I am aware that any false, misleading or incomplete statements made on this application could be grounds for non-admission to, or later dismissal from, the surgical technology program at Washburn Institute of Technology. Signed Date Subscribed and sworn to before me this day of 20 Notary Public (seal) Date of Expiration Revised 2/6/2014