Surgical Technician Program Application

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1 Contra Costa Medical Career College 4051 Lone Tree Way, Suite C Antioch Ca Phone (925) Fax( 925) Surgical Technician Program Application Date Name (First, MI, Last) Address City, State, Zip Telephone ( ) - Cell ( ) - Social Security Number - - Date of Birth / / (Please show identification with Date of Birth) Month Day Year How did you hear about Contra Costa Medical Career College? (Please be specific) Give name and phone number of person to be notified in case of an emergency: Name Telephone # This program is a 1360 hour program consisting of 800 hours of didactic instruction and 560 hours of externship. Graduation date is to be determined. TOTAL FEES, CHARGES, AND EXPENSES Costs paid to school Application/Registration Fee $ (non-refundable) Tuition $13, (refundable based on refund table) Student Tuition Recovery Fund $32.50 (non-refundable) Total paid to school $13, Out of Pocket Expenses (APPROX.) Text Books and Workbooks $ (non-refundable) Uniform/ shoes $ (non-refundable) Drug screen and Background check $ (non-refundable) CPR/BLS Certification $85.00 (non-refundable) Total out of pocket $ Optional Fee Upon Program Completion Certification Examination $ (non-refundable) If you get a student loan, you are responsible for repaying the loan amount plus any interest. 1

2 EDUCATION Have you graduated from high school or received a high school equivalency diploma (GED)? Yes No Level Name Address Dates Attended Major Year Graduated Degree Received High School Technical/ Business College(s)/ Other Do you speak, read or write a language other than English? Yes No Please specify the language: List any other special training or certification you have: 2

3 EMPLOYMENT HISTORY Company Name Address Employed From - To Job Description Wage Reason for Leaving Have you ever had ANY criminal convictions in the past? Yes No If yes, please explain: Students accepted into the Surgical Technology Program will be required to submit to a CRIMINAL BACKGROUND CHECK prior to the start of the Surgical Technology Program. Felony and certain misdemeanor convictions are not allowed. If you have any questions, please contact the Program Director prior to submitting a program application. Do you have any medical conditions that the school should be aware of? If yes, please list: 3

4 CANCELLATION AND REFUND POLICY The student has the right to cancel this agreement, without further obligation, and obtain a refund of all amounts paid, if notice of cancellation is given to this school before midnight of the third business day following commencement of the program. The student may cancel this agreement and obtain a refund by giving written notice to the school at the address shown at the top of the first page of this agreement. The student may do this by mail or by hand delivery. The written notice of cancellation, if sent by mail, is effective when it is deposited (date stamped) in the mail, properly addressed with postage pre-paid. The student should keep a record of the date, time, and place of mailing any notice of cancellation. WITHDRAWAL FROM COURSE A student has the right to withdraw from this program of instruction at any time, and receive a refund of tuition and amounts paid for equipment. If the student withdraws from the program of instruction after the expiration date of the time for canceling this agreement, the student is obligated to pay only for educational services rendered and any equipment not returned, plus a non-refundable registration fee of $ For example, if a student enrolls in a 100 hour program and withdraws after receiving 35 hours of instruction, and if the student paid a $ registration fee and $2,000 tuition, the school would deduct the $ registration fee from the amount received, divide the remaining $2,000 by the number of hours in the program (2000 / 100 = 20) and multiply that hourly amount times the number of hours received by the student (35 x 20 = $700.) The amount paid, in excess of that amount would be the amount of the refund. ($2,000 - $700 = $1,300 Refund Amount. In addition, the refund would include any amount paid for equipment, which is subsequently returned in good condition. Refund Table 10%, 25%, 50% and 75% Refundable amount 10% refund 25% refund 50% refund 60% refund $13, $12, $10, $6, $5, % stands for percentage of course completed. For the purpose of determining the amount you owe for the time you attended, you shall be deemed to have withdrawn from the course when any of the following occurs: a. You notify the school of your withdrawal or the date of withdrawal b. The school terminates your enrollment c. You fail to attend class for more than 2 days. Withdrawal will be deemed the last date of recorded attendance. If any of your tuition was paid from the proceeds of a loan, then the refund will be sent to the lender or the agency that guaranteed the loan if any. Any remaining amount of refund will first be used to repay any student financial aid programs from which you received benefits in proportion to the amount of the benefits received. Any remaining amount will be paid to you. If there is a balance due, you will be responsible to pay that amount. Student tuition Recovery Fund- (STRF) If you are not a resident of California, you are not eligible for protection under, and recovery from, the student tuition recovery fund. Notice ANY HOLDER OF THIS CONSUMER CREDIT CONTRACT IS SUBJECT TO ALL CLAIMS AND DEFENSE WHICH THE DEBTOR COULD ASSERT AGAINST THE SELLER OF GOODS OR SERVICES OBTAINED PURSUANT HERETO OR WITH THE PURPOSE OR WITH THE PROCEEDS HEREOF. RECOVERY HEREUNDER BY THE DEBTOR SHALL NOT EXCEED AMOUNTS PAID BY THE DEBTOR HEREUNDER. 4

5 Notice of transferability of units and degrees earned at our school Units are not transferable to any other school or college and cannot be applied to obtaining a higher level degree at any other college or university. NOTICE OF STUDENT RIGHTS 1. You may cancel your contract for school, without any penalty or obligation on the fifth business day following your first class session as described in the Notice of Cancellation form that will be given to you at the first class you go to. Read the notice of cancellation form for an explanation of your cancellation rights and responsibilities. If you have lost your Notice of Cancellation form, ask the school for a sample copy. 2. After the end of the cancellation period, you also have the right to stop school at any time, and you have the right to receive a refund for the part of the course not taken. Your refund rights are described in the contract. If you have lost your contract, ask the school for a description of the refund policy. 3. If the school closes before you graduate, you may be entitled to a refund. Contact the Bureau of Private Postsecondary and Vocational Education at the address and telephone number printed below for information. CONSIDER THE FOLLOWING QUESTIONS REGARDING PHYSICAL REQUIREMENTS. IF YOU ARE NOT ABLE TO MEET ALL THE FOLLOWING PHYSICAL REQUIREMENTS, YOU MAY WISH TO DISCUSS THE MATTER WITH THE SURGICAL TECHNOLOGY PROGRAM DIRECTOR. IS YOUR EYESIGHT SUFFICIENT TO MAKE AND REPORT VISUAL PATIENT OBSERVATIONS, EVALUATE, READ AND CARRY OUT WRITTEN AND/ OR VERBAL ORDERS? IS YOUR HEARING SUFFICIENT TO HEAR VERBAL ORDERS, ALARMS AND DISTRESS CALLS FROM PATIENTS? IS YOUR MOTOR COORDINATION SUFFICIENT TO MANIPULATE SURGICAL EQUIPMENT AND ACCESSORIES? IS YOUR PHYSICAL STAMINA SUFFICIENT TO ENDURE 8 HOUR PERIODS OF TIME BEING IN A STANDING POSITION, MOVING OR HELPING LIFT PATIENTS THAT MAY BE OF GREATER SIZE AND WEIGHT? ARE YOUR VERBAL AND WRITTEN SKILLS SUFFICIENT TO EFFECTIVELY COMMUNICATE WITH PATIENTS AND MEDICAL STAFF IN ENGLISH? ARE YOUR INTELLECTUAL AND EMOTIONAL FUNCTIONS SATISFACTORY TO ENSURE PATIENT SAFETY AND TO EXERCISE INDEPENDENT JUDGMENT AND DISCRETION IN THE PERFORMANCE OF ASSIGNED SURGICAL TECHNOLOGY RESPONSIBILITIES WHILE UNDER STRESS? Are you able to meet the minimum technical skills standards for the program to which you are applying? Yes No If No, explain: 5

6 All applicants must be able to provide a copy of written documentation from a physician upon acceptance: Proof of Varicella (Chicken Pox) immunity as shown by (a) physician documented history of the disease or (b) documentation of two immunizations or (c) a serum titer containing immunity. Proof of (a) a complete (3 injection series) Hepatitis B Vaccination or (b) a serum titer confirming immunity. Proof of (a) Measles, Mumps and Rubella Vaccination (MMR) or (b) a serum titer confirming immunity to each disease or (c) proof the student was born prior to January 1, Proof of Tetanus vaccination within the last 10 years. Two Negative TB Skin Test (Mantoux PPD) must be within the last 12 months. CPR Certified, Healthcare Provider. ( Offered at CCMCC) Proof of Medical Insurance An incomplete application will not be Considered for selection into the program. I hereby certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or falsification of information is cause for denial of admission or expulsion from the College. I understand that the information contained in this application will be read by the faculty and staff of the Contra Costa Medical Career College Surgical Technology Program. Signature of Applicant Date 6

7 If you have any complaints, questions or problems that you cannot work out with the school, write or call the Bureau for Private Postsecondary and Vocational Education: 1625 North Market Blvd., Suite S202 Sacramento, CA (916) Fax (916) I understand this agreement is not operative until I attend the first class or session of instruction. I further understand that the catalog and its contents are part of this enrollment agreement and that information presented therein is binding on the school and me. I also understand that CCMCC has up to 90 days to place me in an externship. CCMCC will do it s best to place you in a timely manner. I understand that CCMCC will place me in an externship only after I pass the didactic portion of the program, successfully passed all lab skills, and that all required course work and assignments have been completed and turned in, and all financial obligations have been met. If immunization titers, drug screen, background check, HS diploma or equivalency, and resume is not received, CCMCC will not be able to place you in an externship facility per the contracts between the externship sites and CCMCC. When placed I understand that I may have to travel more than 70 miles. I understand that CCMCC will offer 1 externship site, if I am unable to accept this site, I will be responsible for finding my own externship facility and cannot apply for externship at a facility in which CCMCC is contracted with. I also understand I will not be covered under the insurance policy that the CCMCC provides to externship sites. I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatement of fact, I am subject to disqualification and dismissal and to such other penalties as may be prescribed by law or personnel regulations. I understand that my signature grants consent to verify all information and statements made on this application. My signature below certifies that I have read. Understood and agreed to my rights and responsibilities, and that the institutions cancellation and refund policies have been clearly explained to me. Print Name Signature Date This agreement is a legally binding instrument when signed by the student and accepted by the school. Your signature on this agreement acknowledges that you have been given reasonable time to read and understand it and that you have been given: a written statement of the refund policy including examples of how it applies and: a catalog including a description of the course or educational service including all material facts concerning the school and the program or course of instruction which are likely to affect your decision to enroll. Immediately upon signing this agreement, you will be given a copy of it to retain for your records. GOOD LUCK! 7

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