Lake Washington Institute of Technology Dental Hygiene Bachelor of Applied Science Application and Forms-Summer 2018

Transcription

1 Lake Washington Institute of Technology Dental Hygiene Bachelor of Applied Science Application and Forms-Summer 2018 This document contains the application form for the Dental Hygiene BAS program. It should also be used for reapplication to the program. This application works in tandem with the Supporting Information document supplied at under the Admissions Requirements heading. You are responsible for reading all supporting information. Please allow adequate processing time for all documents and transcripts you need to submit to LWTech. In order to create a fair selection process, we will only consider application packets to be complete when they include all the necessary transcripts and other documents and have met the stated deadline. We do not contact applicants who have missing documents. You should download and print this application. To request disability accommodations in the application process, contact Disability Support Services: (425) ; Fax: (425) ; dssinfo@lwtech.edu. Step 1. Step 2. Read the Supporting Information document at under the Admissions Requirements heading. It contains detailed information about the program prerequisites and other eligibility requirements. It will familiarize you with the selection criteria (points structure) used in admission to this program. If you are a first time applicant, fill out this entire application and make copies of all materials you plan to mail or hand deliver to the Enrollment Services office. OR Step 3. If you are a re-applicant, read the entire Supporting Information under the Admissions Requirements heading. Follow the instructions supplied for re-applicants. Make copies of all materials you plan to mail or hand deliver to the Enrollment Services office. Application Packet Mailing Address: Hand Deliver Application Packet to: APPLICATION FOR ADMISSION DENTAL HYGIENE LAKE WASHINGTON INSTITUTE OF TECHNOLOGY ND AVENUE NE KIRKLAND, WASHINGTON Enrollment Services West 201, (walk-up windows or Information Center) Application material must be in an envelope and labeled: Your Name APPLICATION FOR ADMISSION DENTAL HYGIENE LAKE WASHINGTON INSTITUTE OF TECHNOLOGY 1

2 PERSONAL INFORMATION LWTech Student ID #: Last Name First Name Middle Initial Address, including apartment number City State Zip Code Day Phone Ext. Evening Phone Ext. Address LWTECH student ( first name ) (last name) Name of last high school attended: Previous Names All from Admissions will be sent to your LWTECH account. This includes notification of selection results. Year graduated or completed GED: City and State: MANDATORY APPLICATION CHECKLIST Required to apply LWTech Course Number/Title BIOL&241 Anatomy& Physiology I BIOL&242 Anatomy & Physiology II CHEM&121 Intro to Chemistry CHEM&131 Biochemistry BIOL&260 Microbiology ENGL&101 or 102-pick one for scoring Composition or Research Writing College Name Other College Number/Title Term/Year Credits Grade Optional to apply-all courses must be completed by the end of spring quarter 2018 note any classes that are in progress LWTech Course Number/Title College Name Other College Number/Title Engl& 101 OR 102 (ENTER THE ONE NOT BEING SCORED) CMST&210, or 220 or 230 Communications Hum 215 or CMST& 150 NUTR&101 Term/Year Credits Grade 2

3 Nutrition PSYC&100 or PSYC&200 Intro to Psyc. or Lifespan Psyc. SOC&101 Intro to Sociology Math& 146 Introduction to Statistics Optional delayed science class REQUIRED CHECKLIST Official transcripts for all classes listed on page 2. Transcripts are used for verification of prior education. International transcripts must be assessed by approved agency. Do not submit LWTech transcripts. Set up LWTECH student New ATI TEAS or TEAS V. 5 scores that are less than 2 years old submitted to ATI database for LWTech viewing. If TEAS was taken at another college you must pay a transcript fee to ATI for LWTECH admissions to view your score. Two sealed/signed professional recommendation forms (pgs. 6-9) One recommendation must be from a faculty who taught you in a college level class Second recommendation can be from supervisor or co-worker or college adviser. Two sealed/signed RDH observation forms (pgs ) Signed proof from doctor/clinic of 2 of 3 Hepatitis B vaccinations completed (one month apart) OR copy of the current titer showing immunity (Provide 2 copies with your application materials) High school diploma or GED completion information is indicated on page 2 of application Essay-see question on page 6 of supporting information packet for the question and directions $50.00 admissions fee either include a check made out to LWTECH admissions or include paid receipt form college cashier in your application packet. (New summer 2018) Chairside Dental Assisting log form (optional) (p. 14) I am a re-applicant: I most recently applied in (year) I am submitting a new: Chairside Dental Assisting Exp. form I am submitting new RDH observation forms I am submitting New ATI TEAS or Version V. 5 scores that are less than 2 years old scores I am submitting new Transcripts from: I am submitting the new essay: Yes: or No: use my score from my application Year: 3

4 This fully completed checklist is required in my application packet Applicant s Certification: I certify that all statements on this form are true to the best of my knowledge. I verify that all requirements indicated above have been completed and are included in my admissions packet. I have kept a copy of this application for my records. Signature: Date Lake Washington Institute of Technology does not discriminate on the basis of race, color, creed, religion, national origin, sex, sexual orientation, age, gender, marital status, genetic information, disability, or status as a disabled or Vietnam era veteran. Response or non-response to any of the questions listed as voluntary in this application will not affect your consideration for admission. Jurisdiction 7.P.47 WAC 495D The student conduct code shall apply to student conduct that occurs on or off campus and at or in connection with college sponsored activities. Students are responsible for their conduct from the time of application for admission through the actual receipt of a degree, even though conduct may occur before classes begin or after classes end, and during the academic year and during periods between terms of actual enrollment. These standards shall apply to a student s conduct even if the student withdraws from college while a disciplinary matter is pending. The college has sole discretion, on a case by case basis, to determine whether the student conduct code will be applied to conduct that occurs off-campus. B891 summer

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6 LAKE WASHINGTON INSTITUTE OF TECHNOLOGY DENTAL HYGIENE BAS RECOMMENDATION FORM PAGE 1 FACULTY RECOMMENDATION FORM To Applicant: Do not submit letters of recommendation (this form is required). Complete section A and then give this form to the person completing your recommendation, along with a stamped envelope addressed to you or you can have your recommender give the sealed recommendation back directly to you. When you receive your completed, sealed recommendation forms, leave them in the signed envelope and include with your Dental Hygiene application packet. A. APPLICANT INFORMATION (this section is to be completed by the applicant. Please print.) Last Name First Name Middle Initial Today s Date Previous Last Name(s) Birth date (Month/Day/Year) Name of Recommender Recommender s Telephone Number Address of Recommender (Street) (City) (State and ZIP Code) In what capacity and for how long have you known the Recommender? Instructor/Faculty According to the Family and Educational Rights and Privacy Act of 1974, as amended, students are guaranteed access to educational records concerning them, unless that right is waived. Your signature below is optional: however, you (applicant) should check with recommender to ensure that he/she is willing to submit this form without the guarantee of confidentiality. I hereby waive any and all rights to inspect and review this recommendation, and I give my permission for this reference to remain confidential between Lake Washington Institute of Technology and the recommender. Signature of Applicant Date To the Recommender: The applicant is seeking admission to the Dental Hygiene Program at Lake Washington Institute of Technology. To help us assess the applicant s ability to successfully complete this program, we would appreciate your candid opinion regarding the qualities listed on the front and back of this form. Please return this form in the envelope provided to you by the applicant, please sign the back of the envelope flap. Thank you, Dental Hygiene Program Evaluation Committee B. ACADEMIC HISTORY (The following sections are to be completed by the Recommender.) Recommender: Please respond to this academic section only if you have knowledge of the applicant s academic history.) Does the applicant s academic history indicate probable success in the LWTech Dental Hygiene Program? Yes If not, please explain. No C. GENERAL COMMENTS B891 summer

7 Evaluate the applicant by checking the appropriate rating Initiative / Motivation Exceptional Above Average Average Below Average Major Concern Unable to Evaluate Responsibility (reliability, punctuality, integrity) Quality of work (accuracy, timeliness, consistency) Communication Skills Ability to problem solve Ability to work under pressure (response to conflict & stress) Ability to work as a team member Judgment and common sense Self-Confidence / Self-awareness (of own strengths and weaknesses) Acceptance of feedback OVERALL RECOMMENDATION FOR ADMISSION TO DENTAL HYGIENE PROGRAM I strongly recommend the applicant for admission without reservation I recommend the applicant for admission I recommend the applicant with some reservation I do not recommend the applicant for admission RECOMMENDER SIGNATURE Signature of Recommender Today s Date Printed Name of Recommender Recommender s Telephone Number Title Name of Organization Address(Street) (City) (State and ZIP Code) B891 summer

8 LAKE WASHINGTON INSTITUTE OF TECHNOLOGY DENTAL HYGIENE BAS RECOMMENDATION FORM PAGE 1 To Applicant: Do not submit letters of recommendation (this form is required). Complete section A and then give this form to the person completing your recommendation, along with a stamped envelope addressed to you or you can have your recommender give the sealed recommendation back directly to you. When you receive your completed, sealed recommendation forms, leave them in the signed envelope and include with your Dental Hygiene application packet. A. APPLICANT INFORMATION (this section is to be completed by the applicant. Please print.) Last Name First Name Middle Initial Today s Date Previous Last Name(s) Birth date (Month/Day/Year) Name of Recommender Recommender s Telephone Number Address of Recommender (Street) (City) (State and ZIP Code) In what capacity and for how long have you known the Recommender? Instructor/Faculty Supervisor Employer Academic Advisor Co-worker Counselor: According to the Family and Educational Rights and Privacy Act of 1974, as amended, students are guaranteed access to educational records concerning them, unless that right is waived. Your signature below is optional: however, you (applicant) should check with recommender to ensure that he/she is willing to submit this form without the guarantee of confidentiality. I hereby waive any and all rights to inspect and review this recommendation, and I give my permission for this reference to remain confidential between Lake Washington Institute of Technology and the recommender. Signature of Applicant Date To the Recommender: The applicant is seeking admission to the Dental Hygiene Program at Lake Washington Institute of Technology. To help us assess the applicant s ability to successfully complete this program, we would appreciate your candid opinion regarding the qualities listed on the front and back of this form. Please return this form in the envelope provided to you by the applicant, please sign the back of the envelope flap. Thank you, Dental Hygiene Program Evaluation Committee B. ACADEMIC HISTORY (The following sections are to be completed by the Recommender.) Recommender: Please respond to this academic section only if you have knowledge of the applicant s academic history.) Does the applicant s academic history indicate probable success in the LWTech Dental Hygiene Program? Yes If not, please explain. No C. GENERAL COMMENTS B891 summer

9 Evaluate the applicant by checking the appropriate rating Initiative / Motivation Exceptional Above Average Average Below Average Major Concern Unable to Evaluate Responsibility (reliability, punctuality, integrity) Quality of work (accuracy, timeliness, consistency) Communication Skills Ability to problem solve Ability to work under pressure (response to conflict & stress) Ability to work as a team member Judgment and common sense Self-Confidence / Self-awareness (of own strengths and weaknesses) Acceptance of feedback OVERALL RECOMMENDATION FOR ADMISSION TO DENTAL HYGIENE PROGRAM I strongly recommend the applicant for admission without reservation I recommend the applicant for admission I recommend the applicant with some reservation I do not recommend the applicant for admission RECOMMENDER SIGNATURE Signature of Recommender Today s Date Printed Name of Recommender Recommender s Telephone Number Title Name of Organization Address(Street) (City) (State and ZIP Code) B891 summer

10 Dental Hygiene BAS Program-Lake Washington Institute of Technology Observation of Dental Hygienist Reporting Form Applicant: To document clinical observation experience at more than one location, please provide a copy of this form to each RDH. The following person is an applicant to the LWTech Dental Hygiene Program. Applicants must submit documentation of their previous/current observation of a registered Dental Hygienist in a clinical setting. Please complete and return this form as soon as possible to the applicant in a sealed envelope with your signature across the seal. This applicant will not be considered for the Dental Hygiene Program until this form is returned. Applicant Last Name Applicant First Name Middle Initial Applicant Address (Street) (City) (State and ZIP Code) According to the Family and Educational Rights and Privacy Act of 1974, as amended, students are guaranteed access to educational records concerning them, unless that right is waived. Your signature below is optional: however, you (applicant) should check with recommender to ensure that he/she is willing to submit this form without the guarantee of confidentiality. I hereby waive any and all rights to inspect and review this recommendation, and I give my permission for this reference to remain confidential between Lake Washington Institute of Technology and the recommender. Signature of Applicant Date Please circle: Yes No Applicant arrived promptly for observation and stayed agreed upon hours Yes No Applicant s appearance was appropriate for the clinic setting Yes No Applicant showed effective listening skills and good verbal communication Yes No Applicant observed attentively and with interest Yes No Applicant s questions and comments indicate an attempt to learn about the field of Dental Hygiene RDH Name: RDH Signature: Title: Clinic Name: Hours spent observing: Date: DHYG License #: Clinic Phone: (Required for verification) (Required for verification) Comments (include additional comments on the back of this form as needed): B891 summer

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12 Dental Hygiene BAS Program-Lake Washington Institute of Technology Observation of Dental Hygienist Reporting Form Applicant: To document clinical observation experience at more than one location, please provide a copy of this form to each RDH. The following person is an applicant to the LWTech Dental Hygiene Program. Applicants must submit documentation of their previous/current observation of a registered Dental Hygienist in a clinical setting. Please complete and return this form as soon as possible to the applicant in a sealed envelope with your signature across the seal. This applicant will not be considered for the Dental Hygiene Program until this form is returned. Applicant Last Name Applicant First Name Middle Initial Applicant Address (Street) (City) (State and ZIP Code) According to the Family and Educational Rights and Privacy Act of 1974, as amended, students are guaranteed access to educational records concerning them, unless that right is waived. Your signature below is optional: however, you (applicant) should check with recommender to ensure that he/she is willing to submit this form without the guarantee of confidentiality. I hereby waive any and all rights to inspect and review this recommendation, and I give my permission for this reference to remain confidential between Lake Washington Institute of Technology and the recommender. Signature of Applicant Date Please circle: Yes No Applicant arrived promptly for observation and stayed agreed upon hours Yes No Applicant s appearance was appropriate for the clinic setting Yes No Applicant showed effective listening skills and good verbal communication Yes No Applicant observed attentively and with interest Yes No Applicant s questions and comments indicate an attempt to learn about the field of Dental Hygiene RDH Name: RDH Signature: Title: Clinic Name: Hours spent observing: Date: DHYG License #: Clinic Phone: (Required for verification) (Required for verification) Comments (include additional comments on the back of this form as needed): B891 summer

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14 Lake Washington Institute of Technology EMPLOYEE CHAIRSIDE DENTAL ASSISTING VERIFICATION Employee: Position: Start date: End date: Total hours chairside dental assisting: Total hours worked to date: (Please do not enter hours per week.) Specific duties: (Applicant: Describe duties performed in detail: attaching a job description without applicant description will not suffice and will result in no points awarded in this category). Please use this form to describe your duties. Employer: Address: Employer s signature Phone #: Required for verification Date This form must be returned to the applicant in a sealed envelope, with your signature across the seal, so that the applicant may turn it in with the application materials; he/she will not receive recognition for the work if not submitted B891 summer