Emergency Medical Technician

Size: px
Start display at page:

Download "Emergency Medical Technician"

Transcription

1 Emergency Medical Technician Admission Requirements EMERGENCY MEDICAL TECHNICAL IMPORTANT: PLEASE READ CAREFULLY

2 Classes are held on Tuesday and Thursday nights from 5:00 p.m. until 9:00 p.m. All classes are held at the campus located in Mayhew, Mississippi; classes are limited to 30 students. In order to be considered for admission to this class, you must have the following information on file in the Counseling Office (Golden Triangle Campus) before you can register for classes. Deadlines are: Spring---December 1 st Fall August 1st Admission Requirements: 1. A completed application to EMCC Golden Triangle. 2. A copy of your valid driver s license showing you to be 18 years old before the beginning date of the EMT class. 3. An official transcript from your high school showing date of graduation or official GED transcript showing high school equivalency. 4. A minimum scale score of 77 on the Reading section of the COMPASS or a minimum ACT composite of 16 if taken after October 1989 or composite of 12 if taken before A valid CPR certification card (Heath Care Provider Level). 6. A physical examination showing you to be physically fit per physician (dated within six months prior to beginning date of the EMT class) with a current shot record (report should include dates of Tetanus (dated within 10 years) and childhood vaccines ). Proof of Tuberculin test (dated within 1 year) and proof of starting the Hepatitis B vaccinations prior to clinical and ambulance rotations OR a declination form regarding the Tuberculin test and Hepatitis B vaccinations must be in the your admission file. The COMPASS test will be administered based on the enclosed schedule at a cost of $20. The ACT test will also be administered based on the enclosed schedule at a cost of $35. Testing for the COMPASS and the ACT could take up to 4 hours. In order to reserve a seat for the Compass and ACT test, you must pay in the business office and sign up for the next available test that fits your schedule.

3 The EMT program has been approved for a credit of 8 semester hours. Tuition is $ , registration is $65.00, liability insurance is $76.80, program fee is $100.00, books are approximately $141.00, and parking decal is $15.00 for a total of $ All fees are due upon registration/first night of class. There is no financial aid available for EMT classes. *NOTE: ALL COSTS ARE APPROXIMATE AND SUBJECT TO CHANGE. COSTS ARE BASED ON EXPENSES. Felony convictions may impact your ability to complete the program. For additional information, please contact John McBryde at before registering for this program. If you have any questions, please contact the counselor at Name of Student: Date:

4 I. Physical: TO BE COMPLETED BY A PHYSICIAN Physician s Name: Address: Phone: Physical Examination: Vital Signs: BP: Pulse: Resp.: Height: Weight: General Appearance Neck/Head Nutritional Status Eyes Chest Peripheral Vascular Visual Acuity Lungs Musculoskeletal Ears Heart Neurological Auditory Acuity Abdomen Skin Nose/Throat Breast Axillae Current Treatment: In your opinion, is there any health problem which would interfere with this individual s ability to pursue a program of study and/or a career in an allied health program? Remarks/Special Recommendations: Date of Examination: _ Signed:, M.D. ANNUAL DIAGNOSTIC TEST/RESULTS Mantoux Turberuculin Skin Test (IF NEGATIVE, NO CHEST X RAY REQUIRED) Date: Result: Signed, M.D. or R.N. (Or) Negative Chest X Ray Date Previous physical transfer statement: Has student been under the care of a physician or been hospitalized since this physical was completed? Yes: No: Signed, M.D. or R.N. Name of Student: Date: II. Physical: TO BE COMPLETED BY A PHYSICIAN The following information must be certified by the physician or Health Department:

5 Immunizations must be current with dates listed. Date: Diptheria/Tetanus (must be dated within 10 years) Polio (date of SOS ) Mumps Vaccine OR Previous History of the Disease Measles (Rubeola) Vaccine (Once since 1967) OR Previous History of the Disease German Measles (Rubella) Vaccine (Adolescence or Adulthood) OR Positive Titer Hepatitis B Vaccination Dates 1 st Dose 2 nd Dose 3 rd Dose Proof of immunizations and skin test is required (either a copy of the official report/certificate or information signed by the physician). Physician s Name:, M.D. OR Health Department For Office Use Only Hepatitis Immunization Coordinators Initials

6 FALSIFICATION OF INFORMATION IS A BASIS FOR DENYING ADMISSION OR FOR IMMEDIATE TERMINATION OF ENROLLMENT. Student Health Record Student (Print ) Date of Birth Last First Middle Parent/Guardian / Spouse Student Home Phone Home Address City State Zip Have you ever had or do you now have any of the following? (Please check to the right of each item.) Arthritis Asthma Back Problems Chest Pain Chronic Cough Diabetes Digestive Disturbances Diptheria Ear/Nose/Throat Problems Excessive Bleeding Excessive Weight Loss Eye Problems Foot Problems Frequent Colds Frequent or Severe Headaches German Measles Hay Fever Hearing Difficulties Heart Disease Yes No Yes No Hernia High Blood Pressure Jaundice Kidney Or Bladder Problems Measles Menstrual Disorders Mumps Rheumatic Fever Scarlet Fever Seizure Disorders, Epilepsy Shortness of Breath Skin Disorders Speech Difficulties Swollen or Painful Joints Tooth or Gum Problems Tuberculosis Ulcer Varicose Veins Venereal Disease Do you have any food or drug allergies? List them. What medications are you currently taking? Have you been or are you in drug or alcohol rehabilitation? Do you smoke? Have you had any surgical operations? List them. Have you had any accidents or injuries? List them. Do you have any other health problems? List them. I certify that I have reviewed the information that I have supplied and that it is true and complete to the best of my knowledge. Date: Signed (Student s Signature) Student Date

7 Pulmonary History (May be submitted in lieu of a chest X ray in the event of a previous positive TB test.) 1. Do you have a chronic cough? Yes No 2. Do you Smoke? Yes No If yes, how much? 3. Have you lost weight recently? Yes No If yes, how much? Were you trying to lose weight? Yes No 4. Have you coughed up blood? Yes No If yes, how much? 5. Have you noticed any shortness of breath? Yes No 6. Have you had any night sweats? Yes No 7. Have you been around anyone who has TB? Yes No 8. Have you had a TB test? Yes No A. Was it: Positive or Negative? B. When was it first Positive? C. What medication did you receive and for how long? MISSISSIPPI GED TRANSCRIPT REQUEST

8 (Please Print.) NAME (Name at the time of test) Date of Birth Month Day Year Social Security No. Current Name Current Mailing Address P.O. Box OR Street Address City State Zip Code Telephone No. ( ) Area Code Date GED tests were taken Did you pass the tests and receive a diploma? Name and location of the GED Testing Center GED Diploma No. Date Issued (If known) (If known) PLEASE PRINT NAME AND ADDRESS TO WHICH GED TRANSCRIPT SHOULD BE MAILED: East Mississippi Community College Golden Triangle Campus Office of Admissions P.O. Box 100 Mayhew, MS PLEASE CHECK: $5.00 is enclosed for transcript $5.00 is enclosed for diploma $10.00 is enclosed for both I hereby authorize the State GED Administrator to release my GED transcript to the address listed above. Signature (Signature is required to mail transcript) Date THERE IS A $5.00 CHARGE FOR A COPY OF YOUR TRANSCRIPT. PAYMENT MUST BE MADE BY CASHIER CHECK, CERTIFIED CHECK, OR MONEY ORDER. PLEASE MAKE IT PAYABLE TO THE SBCJC. THERE IS AN ADDITIONAL CHARGE OF $5.00 IF YOU REQUEST ANOTHER DIPLOMA. PAYMENT MUST BE MADE CASHIER CHECK, CERTIFIED CHECK, OR MONEY ORDER. PLEASE MAKE IT PAYABLE TO THE SBCJC. PERSONAL CHECK OR CASH WILL NOT BE ACCEPTED. MAIL THIS FORM TO: State Board for Community and Junior Colleges State GED Office 3825 Ridgewood Road Jackson, Mississippi 39211

Hinds Community College Nursing and Allied Health Programs Health Record Packet

Hinds Community College Nursing and Allied Health Programs Health Record Packet Health Record Packet All Clinical Requirements (including the NAH Health Record Packet) must be submitted by the health profession program s designated date. For students admitted to a new program, failure

More information

Hinds Community College Nursing and Allied Health Programs Clinical Record Packet

Hinds Community College Nursing and Allied Health Programs Clinical Record Packet Clinical Record Packet General Directions & Information All clinical requirements must be submitted by the health profession program s designated due date. Failure to submit Clinical Record Packet requirements

More information

Cumberland County College RADIOGRAPHY PROGRAM Medical History Information

Cumberland County College RADIOGRAPHY PROGRAM Medical History Information P R I D E S E R V I C E E X C E L L E N C E Cumberland County College RADIOGRAPHY PROGRAM Medical History Information Return to: Radiography Department Cumberland County College P.O. Box 1500, College

More information

HEALTH SCIENCE PROGRAMS Chipola College Marianna, Florida 32446 PARAMEDIC CERTIFICATE PROGRAM

HEALTH SCIENCE PROGRAMS Chipola College Marianna, Florida 32446 PARAMEDIC CERTIFICATE PROGRAM Revised 3/05 HEALTH SCIENCE PROGRAMS Chipola College Marianna, Florida 32446 PARAMEDIC CERTIFICATE PROGRAM The class meets on Tuesday, Wednesday and Thursday from 12:00 p.m. until 6:00 p.m. The classes

More information

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS NURSING STUDENT HEALTH & IMMUNIZATION RECORDS *********************************** COMPLETE THE ATTACHED HEALTH PACKET AND SUBMIT TO THE NURSING DEPARTMENT NO LATER THAN THE ASN ORIENTATION. **************************************

More information

Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges

Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges To: From: Re: Medical Staff Applicants K. Bruce Simmons, MD Director, Requirements for Medical Clearance EMPLOYEE/STUDENT HEALTH Jacobsen Hall 315-464-4260 (telephone) 315-464-5471 (fax) The New York Department

More information

Dear Prospective Certified Nursing Assistant Student:

Dear Prospective Certified Nursing Assistant Student: Dear Prospective Student: We are pleased to welcome you to Alvin Community College and look forward to assisting you in starting your career goals in healthcare. As a, you will have many doors of opportunity

More information

Trinitas School of Nursing Health Clearance Information

Trinitas School of Nursing Health Clearance Information Trinitas School of Nursing Health Clearance Information Students are required to have health clearance before they are allowed to register for NURE 131 and higher courses. All NURE 132, NURE 231, NURE

More information

Nurse Aide. Clinicals ** April 25 April 27, 2016 7:00 A.M. 3:00 P.M. or 6:00 A.M.-2:00 P.M.

Nurse Aide. Clinicals ** April 25 April 27, 2016 7:00 A.M. 3:00 P.M. or 6:00 A.M.-2:00 P.M. Nurse Aide January 11, 2016 February 11, 2016 5:00-9:00 P.M., Monday-Thursday Clinicals ** February 15 17, 2016 7:00 A.M. 3:00 P.M. or 6:00 A.M.-2:00 P.M. March 21, 2016 April 21, 2016 5:00-9:00 P.M.,

More information

Department of State Academic Exchanges Participant Medical History and Examination Form

Department of State Academic Exchanges Participant Medical History and Examination Form Department of State Academic Exchanges Participant Medical History and Examination Form Having been selected to participate in a U.S. Department of State educational exchange program, you are required

More information

1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form

1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Mail completed form to: Marlin Health Services 1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Virginia State law (code 23-7.5) requires all

More information

GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434

GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434 GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434 HEALTH REQUIREMENTS M e d i c a l Assistant Certificate (

More information

Dear Incoming Student:

Dear Incoming Student: FOR THE ADVANCEMENT OF SCIENCE AND ART Dear Incoming Student: It is mandatory that you complete and return the enclosed Cooper Union health forms and the New York State required response forms for Meningitis,

More information

2015 Medical Requirement Forms

2015 Medical Requirement Forms PLEASE RETAIN A COPY OF THE COMPLETED HEALTH FORMS FOR YOUR OWN RECORDS 2015 Medical Requirement Forms Ontario Public Health regulations and St. Clair College Policy require health screening for all persons

More information

TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD

TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD TRINITAS SCHOOL OF NURSING STUDENT HEALTH RECORD Please complete this form to the best of your ability and bring it to your Physician, Nurse Practitioner or Physician s Assistant for your physical examination.

More information

HUNTER COLLEGE OF THE CITY UNIVERSITY OF NEW YORK HUNTER-BELLEVUE SCHOOL OF NURSING HEALTH REQUIREMENTS AND CLINICAL PRACTICE CLEARANCE

HUNTER COLLEGE OF THE CITY UNIVERSITY OF NEW YORK HUNTER-BELLEVUE SCHOOL OF NURSING HEALTH REQUIREMENTS AND CLINICAL PRACTICE CLEARANCE HUNTER COLLEGE OF THE CITY UNIVERSITY OF NEW YORK HUNTER-BELLEVUE SCHOOL OF NURSING HEALTH REQUIREMENTS AND CLINICAL PRACTICE CLEARANCE All undergraduate students entering clinical courses are required

More information

PRE-EMPLOYMENT HISTORY AND PHYSICAL

PRE-EMPLOYMENT HISTORY AND PHYSICAL MIDWESTERN UNIVERSITY OPTI - AZCOM PRE-EMPLOYMENT HISTORY AND PHYSICAL Name Department Birth Date Age Position MEDICAL HISTORY Childhood Illnesses & Immunizations Please check the following childhood diseases

More information

Please note that all dates, times and fees listed are subject to change without notice.

Please note that all dates, times and fees listed are subject to change without notice. May 21, 2012 Dear Prospective Student: Thank you for considering Simi Valley Adult School and Career Institute as you pursue a career as an X-ray Technician. This is a limited permit program that prepares

More information

STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS. For Students

STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS. For Students STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS For Students 1. Fill out the student sections on pages 1, 2 and 5. Take all the pages with you to your physical exam appointment. 2. During your physical exam,

More information

LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)

LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003) SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty

More information

Summa Center for EMS EMT Program Website: www.summa-ems.org Accreditation #324. Note that this course is limited to the first 20 applicants.

Summa Center for EMS EMT Program Website: www.summa-ems.org Accreditation #324. Note that this course is limited to the first 20 applicants. Enclosed is the application packet for the Fall 2015 EMT Course which begins on July 28 th and will be held on the Akron City Hospital Campus, Idabelle Firestone Center (School of Nursing). Note that this

More information

STUDENT HEALTH REQUIREMENTS

STUDENT HEALTH REQUIREMENTS STUDENT HEALTH REQUIREMENTS All students who are accepted at The Christ College of Nursing and Health Sciences are required to complete a health screening and provide documented immunity to specific diseases

More information

All Nursing Students. Yearly Physical Exam, Current CPR Card, Personal Health Insurance, Malpractice Insurance (Graduate Students only)

All Nursing Students. Yearly Physical Exam, Current CPR Card, Personal Health Insurance, Malpractice Insurance (Graduate Students only) To: Subject: All Nursing Students Yearly Physical Exam, Current CPR Card, Personal Health Insurance, Malpractice Insurance (Graduate Students only) All nursing students must meet the following criteria

More information

FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST

FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST Department of Public Safety - Technology 11400 Greenstone Avenue Santa Fe Springs California 90670 Tracy Rickman, Academy Coordinator (562) 941-4082 Class FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST

More information

MIAMI DADE COLLEGE MEDICAL CAMPUS SCHOOL OF HEALTH SCIENCES EMERGENCY MEDICAL SERVICES Emergency Medical Technician (EMT) Application Packet

MIAMI DADE COLLEGE MEDICAL CAMPUS SCHOOL OF HEALTH SCIENCES EMERGENCY MEDICAL SERVICES Emergency Medical Technician (EMT) Application Packet MEDICAL CAMPUS SCHOOL OF HEALTH SCIENCES EMERGENCY MEDICAL SERVICES Emergency Medical Technician (EMT) Application Packet Student Name (Print) Student Number The information in this 8 - page packet must

More information

LEHMAN COLLEGE DEPARTMENT OF NURSING ANNUAL HEALTH CLEARANCE REQUIREMENTS

LEHMAN COLLEGE DEPARTMENT OF NURSING ANNUAL HEALTH CLEARANCE REQUIREMENTS ANNUAL HEALTH CLEARANCE REQUIREMENTS Each student in the Department of Nursing must have current health clearance prior to each clinical nursing course (NUR 301, 303, 304, 400, 405, 409). Health clearance

More information

ELK CREEK RANCH - HEALTH RECORD PO Box 1476, Cody, WY

ELK CREEK RANCH - HEALTH RECORD PO Box 1476, Cody, WY Please attach a copy of your insurance card. ELK CREEK RANCH - HEALTH RECORD Rancher!s Name Date of Birth Parent or Guardian Work Family Physician Name of individual who may take responsibility in the

More information

1419 Salt Springs Road Syracuse, NY 13214-1301 315-445-4440 (Health Office)

1419 Salt Springs Road Syracuse, NY 13214-1301 315-445-4440 (Health Office) 1419 Salt Springs Road Syracuse, NY 13214-1301 315-445-4440 (Health Office) Dear FAMILY NURSE PRACTITIONER Student: Congratulations! As Nurse Manager of the Wellness Center I would like to welcome you

More information

We offer two schedules for our RN Refresher program:

We offer two schedules for our RN Refresher program: Dear Prospective Student, Thank you for your interest. Attached you will find an application to participate in an innovative R.N. Refresher course sponsored jointly by Molloy College Continuing Education

More information

Summer Youth Musical Theater Workshop Registration Form

Summer Youth Musical Theater Workshop Registration Form 2015 Summer Youth Musical Theater Workshop Registration Form PLEASE READ THIS FORM CAREFULLY Please complete the entire registration form and mail it along with your enrollment fee to: Musicals at Richter,

More information

EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS

EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS EL CENTRO COLLEGE CENTER FOR ALLIED HEALTH AND NURSING HEALTH OCCUPATIONS ADMISSIONS PHYSICAL EXAMINATION AND IMMUNIZATION REQUIREMENTS In order to comply with the Texas Administrative Code (Title 25 Health

More information

FLORIDA MEMORIAL UNIVERSITY Student Health Services

FLORIDA MEMORIAL UNIVERSITY Student Health Services 1 FLORIDA MEMORIAL UNIVERSITY Student Health Services STATEMENT OF HEALTH INSURANCE COVERAGE FORM Date Due: Office of Student Affairs Miami Gardens, FL 33054 Phone 305-626-3120 Fax 305-626-3715 Florida

More information

RUTGERS SCHOOL OF NURSING - CAMDEN STUDENT HEALTH RECORDS PACKET

RUTGERS SCHOOL OF NURSING - CAMDEN STUDENT HEALTH RECORDS PACKET School of Nursing-Camden Rutgers, The State University of New Jersey Residence Hall 215 North 3 rd Street Camden, NJ 08102-1405 nursing.camden.rutgers.edu nursecam@camden.rutgers.edu Phone: 856-225-6226

More information

APPLICATION FOR THE RN to BSN PROGRAM NAME: ADDRESS:

APPLICATION FOR THE RN to BSN PROGRAM NAME: ADDRESS: APPLICATION FOR THE RN to BSN PROGRAM PLEASE PRINT CLEARLY NAME: ADDRESS: Please check Campus you wish to attend: Rutgers Camden: Atlantic Cape Community College: Camden County College at Blackwood: Home

More information

Teen Volunteer Application

Teen Volunteer Application 68 Ha u p pa u g e Rd Co m m a c k, NY 11725 631-715-2555 w w w.g u r w i n.o r g Office Use Only: Interview : Assignment: Proof of MMR: Reference Sent: Accepted Y or N: Interviewed by: Reference Returned:

More information

Nursing Assistant I Admission Requirements

Nursing Assistant I Admission Requirements Nursing Assistant I Admission Requirements 1. High School Diploma, GED or College Transcripts 2. Driver s License or State ID 3. Social Security Card 4. Physical Examination 5. Criminal Background Check

More information

English Language Fellow Program Health Verification Form

English Language Fellow Program Health Verification Form English Language Fellow Program Health Verification Form You are receiving this Health Verification Form (HVF) because your application was reviewed and determined to be eligible for consideration for

More information

SUSQUEHANNA COUNTY CAREER AND TECHNOLOGY CENTER PO BOX 100, SCHOOL HOUSE ROAD DIMOCK, PA 18816-0100 PHONE: (570)278-9229 FAX: (570)278-3913

SUSQUEHANNA COUNTY CAREER AND TECHNOLOGY CENTER PO BOX 100, SCHOOL HOUSE ROAD DIMOCK, PA 18816-0100 PHONE: (570)278-9229 FAX: (570)278-3913 To: From: Re: Applicant Alice M. Davis, Ph.D. Executive Director School Counselor Director Nurse Aide Training Program Thank you for your interest in our program. Listed below is information that will

More information

Dear Potential Transfer Student,

Dear Potential Transfer Student, Dear Potential Transfer Student, Thank you for your interest in Faulkner State Community College s Nursing Program. The forms and checklist to be completed in order to be considered for transfer are enclosed.

More information

COMPUTED TOMOGRAPHY CERTIFICATE PROGRAM

COMPUTED TOMOGRAPHY CERTIFICATE PROGRAM 1 School of Health Professions COMPUTED TOMOGRAPHY CERTIFICATE PROGRAM APPLICATION PACKET University System of Georgia An Affirmative Action/Equal Opportunity Institution 2 Dear Applicant, Thank you for

More information

MIAMI DADE COLLEGE MEDICAL CAMPUS SCHOOL OF HEALTH SCIENCES EMERGENCY MEDICAL SERVICES Emergency Medical Technician (EMT) Application Packet

MIAMI DADE COLLEGE MEDICAL CAMPUS SCHOOL OF HEALTH SCIENCES EMERGENCY MEDICAL SERVICES Emergency Medical Technician (EMT) Application Packet SCHOOL O HEALTH SCIENCES EMERGENCY MEDICAL SERVICES Emergency Medical Technician (EMT) Application Packet Student Name (Print) Student Number The information in this 8 - page packet must be completed to

More information

COMPUTED TOMOGRAPHY CERTIFICATE PROGRAM

COMPUTED TOMOGRAPHY CERTIFICATE PROGRAM 1 Health Sciences Division COMPUTED TOMOGRAPHY CERTIFICATE PROGRAM APPLICATION PACKET Revised July 2014 2 University System of Georgia! An Affirmative Action/Equal Opportunity Institution DARTON STATE

More information

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION INSURANCE INFORMATION (mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last

More information

COLUMBUS STATE COMMUNITY COLLEGE Nursing, Respiratory, Imaging, Surgical Technology, Sterile Processing, or Medical Assisting Program

COLUMBUS STATE COMMUNITY COLLEGE Nursing, Respiratory, Imaging, Surgical Technology, Sterile Processing, or Medical Assisting Program 1 Nursing, Respiratory, Imaging, Surgical Technology, Sterile Processing, or Medical Assisting Program HEALTH HISTY To be completed by the Student: PLEASE PRINT ALL INFMATION COUGAR I.D. Name: SS#: Last

More information

GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER

GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER Dear Parent, Verde Valley School is committed to providing your child with the best possible care. It is with this goal in mind that the school requires

More information

Wabash Student Health Center

Wabash Student Health Center Wabash Student Health Center Information and Instructions for Completing the Student Health Record Dear Incoming Wabash Student and Parent(s): Welcome to Wabash College! In order to make your experience

More information

Southwestern College Nursing & Health Occupations Programs

Southwestern College Nursing & Health Occupations Programs MEDICAL EXAMINATION FORM TO THE PHYSICIAN: Southwestern College requires a physical examination for students enrolling in the Nursing and Health Occupations Programs. A statement of your knowledge of this

More information

Current (within 1 year) Tuberculin PPD or skin test administration. If PPD results are positive a chest x-ray is required (p. 7).

Current (within 1 year) Tuberculin PPD or skin test administration. If PPD results are positive a chest x-ray is required (p. 7). FAMU SCHOOL OF NURSING PROFESSIONAL LEVEL APPLICATION CHECKLIST For admission to the Professional Nursing Program, applications are only accepted October 1 st -15 th for SPRING and May 1 st -15 th for

More information

HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY

HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY Purpose: Completion of this packet is requested as part of the admissions process. The information you provide

More information

Gaston College Health Education Division Student Medical Form

Gaston College Health Education Division Student Medical Form Student Name: Date: Gaston College Health Education Division Student Medical Form Associate Degree Nursing Cosmetology Dietetic Programs Health and Fitness Science Medical Assisting Nursing Assistant Phlebotomy

More information

Dear Applicant: Sincerely, Grant Wilson Surgical Technology Program Director Calhoun Community College

Dear Applicant: Sincerely, Grant Wilson Surgical Technology Program Director Calhoun Community College Dear Applicant: Thank you for your interest in the surgical technology program. Please complete your application and return it to the Allied Health Department on the third floor of the Health Sciences

More information

SURGICAL TECHNOLOGY PROGRAM APPLICATION

SURGICAL TECHNOLOGY PROGRAM APPLICATION SURGICAL TECHNOLOGY PROGRAM APPLICATION Dear Applicant: Thank you for your interest in Wharton County Junior College s Surgical Technology Program. Information on the program and the requirements necessary

More information

Medical History and Technical Standards Form

Medical History and Technical Standards Form Physical Examinations Effective with the 2001-2002 UWF Catalog, any student applying to enter the Athletic Training Education Program must complete a comprehensive physical examination by a licensed physician.

More information

ACC Nurse Refresher Course Continuing Education Department

ACC Nurse Refresher Course Continuing Education Department ACC Nurse Refresher Course Continuing Education Department Alvin Community College 3110 Mustang Road Alvin, TX 77511 Ph: 281-756-3796 Fax: 281-756-3952 Dear Prospective Nursing Refresher Student, Alvin

More information

APPLICATION FOR ADMISSION

APPLICATION FOR ADMISSION APPLICATION FOR ADMISSION Please attach a $25.00 non-refundable application fee and a current picture of yourself. Desired Entrance Date First Name Middle Name Last Name Suffix (Jr.,Sr.,etc.) Street Address

More information

Print Provider Packet and schedule an appointment with your healthcare provider to complete the packet.

Print Provider Packet and schedule an appointment with your healthcare provider to complete the packet. Due Dates: Incoming Fall Students July 15 th Incoming Spring Students December 15 th Incoming Summer Students July 15 th THESE FOLLOWING ARE REQUIRED BY NJ STATE LAW AND ROWAN UNIVERSITY POLICY. FAILURE

More information

Application Form. Global Green MBA

Application Form. Global Green MBA Faculty of Management The International School Application Form Global Green MBA Instructions All of the following materials must be submitted before your application will be processed: Application Form

More information

ST. ANTHONY HOSPITAL* INSTITUTE OF EMERGENCY MEDICAL TRAINING

ST. ANTHONY HOSPITAL* INSTITUTE OF EMERGENCY MEDICAL TRAINING ST. ANTHONY HOSPITAL* INSTITUTE OF EMERGENCY MEDICAL TRAINING PARAMEDIC ACADEMY Cycle #98 Application Deadline Wednesday April 22, 2015 at 5pm. Application Testing Tuesday April 28 th or Wednesday April

More information

Emergency Medical Technician

Emergency Medical Technician Emergency Medical Technician OVERVIEW: This intensive 3-course program includes lectures and hands-on practice of techniques taught: introduction to emergency care, bleeding and shock, soft tissue injuries,

More information

OAKLAND UNIVERSITY SCHOOL OF NURSING Instructions for completing the Clinical Health Requirements

OAKLAND UNIVERSITY SCHOOL OF NURSING Instructions for completing the Clinical Health Requirements OAKLAND UNIVERSITY SCHOOL OF NURSING Instructions for completing the Clinical Health Requirements Submission Deadline Dates for NEW Accelerated Second Degree and NEW Basic-BSN students Semester Admitted

More information

APPLICATION FOR ADMISSION FALL 2015 GENERAL INFORMATION

APPLICATION FOR ADMISSION FALL 2015 GENERAL INFORMATION BACHELOR OF SCIENCE IN NURSING (RN-BSN Program) APPLICATION FOR ADMISSION FALL 2015 GENERAL INFORMATION 1. Transcripts: In order to be considered for admission to the RN-BSN program, all students must

More information

American Heritage Girls, Inc. Health and Medical History Form This form is valid for 12 months. This form should be kept at the Troop level.

American Heritage Girls, Inc. Health and Medical History Form This form is valid for 12 months. This form should be kept at the Troop level. American Heritage Girls, Inc. Health and Medical History Form This form is valid for 12 months. This form should be kept at the Troop level. Place Photo Here Member Information Member Name: Troop #: Date

More information

Division of Student Affairs Department of Student Health Services

Division of Student Affairs Department of Student Health Services Division of Student Affairs Department of Student Health Services Pre Entrance Health Record Please Complete in Ink or Type Only, Faxes or Copies will not be accepted. Deadline for Submission Return To:

More information

Student Health Forms

Student Health Forms Student Health Forms Graduate Program Important: This packet includes a comprehensive set of forms required by NYS Health law. These forms are required in order to register for classes. Please review each

More information

South Plains College Respiratory Care Fall 2015

South Plains College Respiratory Care Fall 2015 South Plains College Respiratory Care Fall 2015 Hello! We are pleased that you are interested in the South Plains College Respiratory Care Program. The Respiratory Care Program classes are offered exclusively

More information

NURSING. East Mississippi Community College P.O. Box 100 Mayhew, MS 39753 (662) 243-1910 2012-2013 PRACTICAL NURSING ADMISSION REQUIREMENTS

NURSING. East Mississippi Community College P.O. Box 100 Mayhew, MS 39753 (662) 243-1910 2012-2013 PRACTICAL NURSING ADMISSION REQUIREMENTS NURSING East Mississippi Community College P.O. Box 100 Mayhew, MS 39753 (662) 243-1910 2012-2013 PRACTICAL NURSING ADMISSION REQUIREMENTS Disclaimer The content and requirements of this admission packet

More information

Oregon Coast Community College Medical Assistant Program Application 2015-2016 Academic Year Deadline: December 4, 2015

Oregon Coast Community College Medical Assistant Program Application 2015-2016 Academic Year Deadline: December 4, 2015 Oregon Coast Community College Medical Assistant Program Application 2015-2016 Academic Year Deadline: December 4, 2015 Program Description The Oregon Coast Community College Medical Assistant Program

More information

APPLICATION FOR UNDERGRADUATE STUDIES

APPLICATION FOR UNDERGRADUATE STUDIES APPLICATION FOR UNDERGRADUATE STUDIES Application for Admission undergraduate INDIANA BAPTIST COLLEGE 1301 W. County Line Road, Greenwood, IN 46142 New Student Admissions Information:317-882-2345 Website:

More information

Attached is your application packet to the LVN/Paramedic to A.D.N. Mobility Program.

Attached is your application packet to the LVN/Paramedic to A.D.N. Mobility Program. Dear Applicant, Attached is your application packet to the LVN/Paramedic to A.D.N. Mobility Program. Please complete and return the following documents in a folder: Incomplete applications will not be

More information

STUDENT HEALTH CENTER VILLANOVA UNIVERSITY CHECK LIST

STUDENT HEALTH CENTER VILLANOVA UNIVERSITY CHECK LIST CHECK LIST This health record must be COMPLETELY filled out and submitted to the Student Health Center by July 2nd. All students must submit a copy of this health record to the Student Health Center even

More information

Ghazvini Center for Healthcare Education 1528 Surgeons Drive Tallahassee, Florida 32308-4631 850.558.4500 phone 850.558.4510 fax

Ghazvini Center for Healthcare Education 1528 Surgeons Drive Tallahassee, Florida 32308-4631 850.558.4500 phone 850.558.4510 fax Ghazvini Center for Healthcare Education 1528 Surgeons Drive Tallahassee, Florida 32308-4631 850.558.4500 phone 850.558.4510 fax Nurse Assistant Program (HCP0122) 120 hours of instruction $312.00 (in-state

More information

Lighthouse Christian Academy

Lighthouse Christian Academy Lighthouse Christian Academy APPLICATION - FORM 1 of 9 Term 20-20 Date Office Use Only Interviewed By: Status: STUDENT INFORMATION (Please print or type) Name (Last) (First) (Middle) Address (Street) (City)

More information

La Salle University Initial Health and Immunization Form Page - 1

La Salle University Initial Health and Immunization Form Page - 1 La Salle University Initial Health and Immunization Form Page - 1 Attention Before your account can be created for the Health and Immunization Tracking System (hereafter called ITS ), you must have previously

More information

Applying for Admission. 2. Mail the application to the college along with a $20 application fee which is non-refundable.

Applying for Admission. 2. Mail the application to the college along with a $20 application fee which is non-refundable. Application Packet First-Time Students 1. Complete the application and attach a recent photo. Applying for Admission 2. Mail the application to the college along with a $20 application fee which is non-refundable.

More information

Northeast Mississippi Community College Dental Hygiene Technology 101 Cunningham Blvd. Booneville, MS 38829 662-720-7208

Northeast Mississippi Community College Dental Hygiene Technology 101 Cunningham Blvd. Booneville, MS 38829 662-720-7208 Dental Hygiene Technology 101 Cunningham Blvd. Booneville, MS 38829 662-720-7208 Dear Dental Hygiene Applicant, Enclosed is a packet of information about the dental hygiene program at Northeast Mississippi

More information

DENTAL ASSISTANT PROGRAM PROGRAM REQUIREMENT PACKET

DENTAL ASSISTANT PROGRAM PROGRAM REQUIREMENT PACKET DENTAL ASSISTANT PROGRAM PROGRAM REQUIREMENT PACKET 4500 Steilacoom Blvd SW Lakewood, WA 98499 www.cptc.edu DENTAL ASSISTANT APPLICATION PLEASE REFER TO THESE PAGES FOR INFORMATION REGARDING THE ADMISSION

More information

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your

More information

DeSoto County School of Practical Nursing

DeSoto County School of Practical Nursing DeSoto County School of Practical Nursing 310 West Whidden Street Arcadia, Florida 34266 (863) 993-1333 (863) 993-9181 FAX Re: Practical Nursing Program 2015/2016 Dear Applicant, Thank you for your interest

More information

DENTAL ASSISTANT PROGRAM PROGRAM REQUIREMENT PACKET

DENTAL ASSISTANT PROGRAM PROGRAM REQUIREMENT PACKET DENTAL ASSISTANT PROGRAM PROGRAM REQUIREMENT PACKET 4500 Steilacoom Blvd SW Lakewood, WA 98499 www.cptc.edu DENTAL ASSISTANT APPLICATION PLEASE REFER TO THESE PAGES FOR INFORMATION REGARDING THE ADMISSION

More information

MOLLOY COLLEGE Division of Continuing Education and Professional Development C.T. Cross Training Program. Home Phone ( ) Address Work Phone ( )

MOLLOY COLLEGE Division of Continuing Education and Professional Development C.T. Cross Training Program. Home Phone ( ) Address Work Phone ( ) C.T. Cross Training Program Name Home Phone ( ) Address Work Phone ( ) City St. Zip E-mail NYS. License # Expiration Date Years of Experience Name of Employer Please indicate how you intend to complete

More information

Student Health Forms

Student Health Forms Student Health Forms Accelerated Nursing Program Important: This packet includes a comprehensive set of forms required by NYS Health law. These forms are required in order to register for classes. Please

More information

Medical Assisting Curriculum

Medical Assisting Curriculum Application Packet for Admission Medical Assisting Curriculum Any candidate for the Carvas College Medical Assisting program should return a fully completed, neatly filled out application to: Carvas College

More information

Ghazvini Center for Healthcare Education 1528 Surgeons Drive Tallahassee, Florida 32308-4631 850.558.4500 phone

Ghazvini Center for Healthcare Education 1528 Surgeons Drive Tallahassee, Florida 32308-4631 850.558.4500 phone Ghazvini Center for Healthcare Education 1528 Surgeons Drive Tallahassee, Florida 32308-4631 850.558.4500 phone Nurse Assistant Program (HCP0122) Program Code 5024 120 hours of instruction Cost approximately

More information

Student Medical Form for North Carolina Community College System Institutions

Student Medical Form for North Carolina Community College System Institutions Student Medical Form for North Carolina Community College System Institutions GUIDELINES FOR COMPLETING IMMUNIZATION RECORD IMPORTANT The immunization requirements must be met; or according to NC law,

More information

Continuing Education Allied Health Programs Certified Nurse Aide (CNA) - Student Requirements:

Continuing Education Allied Health Programs Certified Nurse Aide (CNA) - Student Requirements: Certified Nurse Aide (CNA) - Student Requirements: STAFF VERIFICATION: DATE: COMMENTS: Desired Class Date: _ Session: CEQ Name: Address: City:, Texas Zip: Phone #: Alt #: Email: Students entering the Certified

More information

TMCC NURSING PROGRAM APPLICATION FOR 2015-2016 FALL ADMISSION

TMCC NURSING PROGRAM APPLICATION FOR 2015-2016 FALL ADMISSION Nursing students are candidates selected for admission into the nursing program of study. The application process for admission into the Associate of Applied Science Practical Nursing Program must be completed

More information

STNA. State Tested Nurse Aide 2014-2015. Prospective Student Information Packet. Adult & Community Education 2323 Lexington Avenue Colum bus, OH 43211

STNA. State Tested Nurse Aide 2014-2015. Prospective Student Information Packet. Adult & Community Education 2323 Lexington Avenue Colum bus, OH 43211 State Tested Nurse Aide STNA Prospective Student Information Packet 2014-2015 Adult & Community Education 2323 Lexington Avenue Colum bus, OH 43211 Phone: 614.365.6000, ext. 241 www.cpsadulted.org 1 Adult

More information

Pharmacy Technician Program

Pharmacy Technician Program Pharmacy Technician Program T ASU-Beebe Advanced Technology and Allied Health www.asub.edu Program 72.238.6950 www.richlandcollege.edu/hp Health Professions Division ASU-Beebe Pharmacy Technician Program

More information

Patient Intake Form. Patient Information. How did you find out about our office?

Patient Intake Form. Patient Information. How did you find out about our office? Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our

More information

MOLLOY COLLEGE DIVISION OF NURSING GRADUATE NURSING PROGRAM. Prior to taking your clinical practicum courses, you are required to have the following:

MOLLOY COLLEGE DIVISION OF NURSING GRADUATE NURSING PROGRAM. Prior to taking your clinical practicum courses, you are required to have the following: MOLLOY COLLEGE DIVISION OF NURSING GRADUATE NURSING PROGRAM TO: FROM: RE: GRADUATE NURSING STUDENTS TAKING ADVANCED PHYSICAL ASSESSMENT (NUR572) AND SUBSEQUENT CLINICAL COURSES Associate Dean and Director,

More information

NURSING ASSISTANT PROGRAM INFORMATION AND

NURSING ASSISTANT PROGRAM INFORMATION AND CENTRAL ARIZONA COLLEGE SKILLS CENTER HEALTHCARE PROGRAMS NURSING ASSISTANT PROGRAM INFORMATION AND ENROLLMENT PACKET One-Stop / Skills Center Job Skills Training Program SkillsCenter6/2008 Central Arizona

More information

Northeast Mississippi Community College Dental Hygiene Technology 101 Cunningham Blvd. Booneville, MS

Northeast Mississippi Community College Dental Hygiene Technology 101 Cunningham Blvd. Booneville, MS Dental Hygiene Technology 101 Cunningham Blvd. Booneville, MS 38829 662-720-7208 Dear Dental Hygiene Applicant, Enclosed is a packet of information about the dental hygiene program at Northeast Mississippi

More information

Attached you will find all the information you should need to be eligible for these programs.

Attached you will find all the information you should need to be eligible for these programs. WEST LOS ANGELES COLLEGE DIVISION OF ALLIED HEALTH MEDICAL ASSISTING PROGRAM 9000 OVERLAND AVE., CULVER CITY, CA 90230-3519 Phone: (310) 287-7226 Fax: (310) 287-4352 Dear Applicant, Thank you for your

More information

Emergency Services Academy Ltd. 2 nd Floor, 161 Broadway Boulevard Sherwood Park AB T8H 2A8

Emergency Services Academy Ltd. 2 nd Floor, 161 Broadway Boulevard Sherwood Park AB T8H 2A8 Emergency Medical Technician/Primary Care Paramedic (EMT/PCP) Program Application Package Please ensure you read all of the instructions completely before submitting your application for an EMT/PCP Program.

More information

Little Einsteins Daycare @ St. Albert Inc. 22 Sir Winston Churchill Avenue, St. Albert, AB T8N 1B4 Phone: 780-486-6740

Little Einsteins Daycare @ St. Albert Inc. 22 Sir Winston Churchill Avenue, St. Albert, AB T8N 1B4 Phone: 780-486-6740 Child s name: Date of registration: Starting Date: Child s age: Male Female Legal Guardian: Mother s Name: Email address: Mother s home phone: Cell # : Mother s place of work: Phone: Is mother allowed

More information

Heritage University New BSN Student Immunization and Screening Instructions

Heritage University New BSN Student Immunization and Screening Instructions Heritage University New BSN Student Immunization and Screening Instructions Congratulations on beginning your career as a professional nurse in the BSN program at Heritage University! During your program

More information

Eastern Shore Community College Practical Nursing Program Application Packet 2015

Eastern Shore Community College Practical Nursing Program Application Packet 2015 Eastern Shore Community College Practical Nursing Program Application Packet 2015 The Eastern Shore Community College School of Practical Nursing was originally Northampton- Accomack Memorial Hospital

More information

MVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms.

MVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms. MVA/ PI Registration Form Is this accident work related? YES or No If yes, stop here and notify front desk for different forms. Date: Patient # Patient Name: DOB; Gender: M or F SSN Address: City/State:

More information

School of Medical Laboratory Science Application Packet

School of Medical Laboratory Science Application Packet Application Packet Please mail completed application packet and required documents to Untied Regional HealthCare System Att; Asma Javed, Program Director School of Medical Laboratory Science 1600 11 th

More information

TEEN VOLUNTEER APPLICATION

TEEN VOLUNTEER APPLICATION TEEN VOLUNTEER APPLICATION First Name Last Name Male/Female Date Home Phone Cell Phone Preferred Phone Address Email Want to receive our email newsletter? Y/N City State Zip Code Social Security # or provide

More information