Certified Clinical Medical Assistant

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1 Application for Certified Clinical Medical Assistant

2 Cumberland Salem Workforce Education Alliance Certified Clinical Medical Assistant Program The Clinical Medical Assistant works in a physician s office or a clinic setting. As a Clinical Medical Assistant you will be trained to help the doctor carry out procedures, care for patients, perform basic lab tests and administer medications. This course combines classroom instruction, including electrocardiography (EKG), with a 160 hour externship to provide you with a complete learning experience. Increasing utilization of medical assistants in the rapidly growing healthcare industry will result in fast employment growth for the occupation. Applicants must apply to this program and a limited number of students will be selected. Eligible applicants must have a high school diploma or equivalent, pass a basic skills math and reading test, and complete a background check. A non-refundable application fee of $75 is required. Upon successful completion of this course, you will receive a certificate of completion as having met the training requirements of the Clinical Medical Assistant. Graduates will take the certification examination for Medical Assistant offered by the National Healthcare Association (NHA). This Program was designed to provide thorough didactic and practical instruction, and a basic systems overview of the role of the medical assistant in a practical setting. Didactic lectures cover the theory, anatomy and terminology pertaining to each system. Practical instruction provides hands-on training in the listed procedures verified through a skills check-off system. The course fees include: national certification exam, CPR for healthcare workers, externship placement, background check and a certificate of completion.

3 Application Instructions 1) All information given on the application form must be typed or neatly printed. 2) The completed application, and any subsequent correspondence, must be mailed to the Cumberland Salem Workforce Education Alliance, PO Box 1500, Vineland, NJ Attention: Nancy Pollard 3) A check or money order for $75.00, non-refundable application fee must be enclosed. 4) Arrange for an official copy of your high school, GED and/or college transcripts to be forwarded to Cumberland Salem Workforce Education Alliance by calling or writing to your high school/or assigned designation if your school no longer exists. Copies of high school diplomas are not acceptable. 5) Applicants are required to ask two individuals to provide letters of recommendation in support of their application (See Letter of Recommendation forms). These references may not be family members. References should be responsible adults who can attest to your ability to successfully complete this training (e.g., employers, instructors, advisors, clergy or medical personnel). References are to be mailed by these individuals to the Cumberland Salem Workforce Education Alliance. 6) Applicants must submit the Immunization & Tests form along with their application, showing proof of Hepatitis B vaccination ( 3 shot series) and recent (one year or less) tuberculin test. 7) In order for the application to be considered, it must be complete.

4 CERTIFIED CLINICAL MEDICAL ASSISTANT PROGRAM APPLICATION Please type or print clearly and mail to: Cumberland County College, Cumberland Salem Workforce Education Alliance, PO Box 1500, Vineland, NJ Attention: Nancy Pollard Name Last First Middle Other/Previous Name (which may appear on records) Address Number & Street Apt. Number City State Zip code Phone: Home: ( ) Work: ( ) Social Security Number Date of Birth How did you hear about our training Program? Extra Curricular Activities (please list all school, community or religious activities in which you have participated. Include all offices which you have held and honors you have received.)

5 Give names and address of the two persons to whom you have submitted the recommendation forms. These references must not be family members. The references should be responsible adults who can attest to your ability to successfully complete this training. Name Title/Position Address Phone ( ) Relationship to Applicant Name Title/Position Address Phone ( ) Relationship to Applicant Educational Background School City Dates Attended Degree High School College Special Certification Employment Present Employer Phone ( ) Address Dates of Employment Nature of Work Name of Employer Phone ( ) Address Dates of Employment Nature of Work

6 CERTIFIED CLINICAL MEDICAL ASSISTANT Statement of Interest Please explain why you wish to work in the health care services field. Applicant s Name Date

7 CERTIFIED CLINICAL MEDICAL ASSISTANT Certificate of Information I certify, to the best of my knowledge, that the information supplied on this application is complete and accurate. Applicants signature Date Cumberland County College admits students without regard for race, color, creed, sex, age, religion, national/ethnic origin, sexual orientation, disability, pregnancy or military status.

8 CERTIFIED CLINICAL MEDICAL ASSISTANT Immunization & Tests Name Age Sex Address City State Zip Immunization & Test History Vaccine Dose Date Hepatitis B 1. / / 2. / / 3. / / Tuberculin Tests Arm / Device / Antigen / Manufacturer Dates Applied / / / Date Read Results (mm) Signature of Examiner Print Name of Examiner Address City State Zip Date

9 RELEASE OF INFORMATION FORM I, (print name), authorize Cumberland Salem Workforce Education Alliance to release all of my records pertaining to my criminal history, which includes my name, social security number, date of birth, address, and student ID number to IdentityPi.com. I understand that the use of my records is limited to and in connection with any audit and the evaluation of continuing education programs, and in connection with the enforcement of the federal and/or state laws. My signature is an acknowledgement that I have read and voluntarily consent to the release of the above-mentioned information. Student Signature Date Address Social Security # Phone Number *SSN is used for criminal background check purposes only cccreleaseofinformationform

10 CLINICAL MEDICAL ASSISTANT Application Checklist check or money order and $75.00 an official high school, GED and/or college transcripts forwarded to the Cumberland Salem Workforce Education Alliance Background check waiver Two letters of recommendation forwarded to Cumberland Salem Workforce Education Alliance Immunization records for Hepatitis B TB screen

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