Medical Laboratory Technician Program Application

Transcription

1 Medical Laboratory Technician Program Application Applications Available: December, 2017 Application Deadline: April 15, 2018 Program Start: Fall, 2018 ADMISSION REQUIREMENTS Attend an Information Session. Please visit for dates and times. Information Sessions can also be viewed online. Students must demonstrate eligibility for ENG 111, ENG 115, or ENG 121 as evidenced by one of the following: o Satisfactory ACT (18 or better) or SAT (510 or better) scores according to the college standard. If available, please submit a copy of the scores to the Records office o Satisfactory scores on the English Placement Test** o Successful completion of noncredit developmental English and reading requirements as determined by ACT or SAT or English Placement Test scores** o Transfer of credits for ENG 111 from other institutions or credits awarded on basis of CLEP or advanced placement exam. Students must demonstrate eligibility for MAT 137 College Algebra by one of the following: o Satisfactory ACT or SAT scores according to the college standard. If available, please submit a copy of the scores to the Records office o Satisfactory scores on the Mathematics Placement Test** o Successful completion of noncredit developmental math courses based on the mathematics placement test scores o Transfer of credit for MAT 012, MAT 037, or MAT 045 from an institution of higher learning o Transfer of credits for MAT 137 course from an institution of higher learning o Students who previously took MAT 121, 131, 141, 142, 151, or 191 can use that course to satisfy the MAT 137 requirements Have a minimum adjusted GPA of 2.0 at AACC. Submitted a photocopy of your Maryland driver s license or government-issued I.D. card or AACC student I.D. card. IMPTANT INFMATION Direct all inquiries regarding the application process to Karen Frank via at klfrank1@aacc.edu. Letters will be sent to students at the address listed on this application the month of June, Any applicant having a change of mailing address, address, or telephone number during the application process must notify the admissions office by at klfrank1@aacc.edu. All health sciences students who are offered admission and/or clinical placement will be required to submit a complete criminal background check and urine drug screen. All student applicants final acceptance in the program shall be contingent upon satisfactory completion of a criminal background check and of a urine drug screen.* All letters of acceptance shall state that the acceptance is conditional and contingent on submission to a criminal background check and urine drug screen as may be required by the program--that results in satisfactory reports. If an accepted student tests positive for an illegal or un-prescribed drug, the student shall be denied admission or terminated from any health sciences program.

2 Separate, additional criminal background checks and urine drug screens may be required by clinical sites prior to placements. Students with an unsuccessful background check or urine screening who is denied by a clinical site that is required to meet program competencies shall be dismissed from the program and their registrations shall be withdrawn from courses related to the program of study. If the student tests positive for an illegal or un-prescribed drug, the student shall be denied admission or terminated from any health sciences program even if a denied placement was not required to meet program competencies. Successful reports of criminal background checks and urine drug screens do not assure eligibility for specific clinical site placement, program completion, and/or eligibility to sit for professional licensure/board examinations. Students are reminded that licensing boards for certain health care occupations and professions may deny, suspend, or revoke a license or may deny the individual the opportunity to sit for an examination even if the individual has completed all program course work if it is determined that an applicant has a criminal history or has been convicted of, or pleads guilty, or pleads nolo contendere or the like to a felony or other serious crime. Successful completion of a health sciences program of study at Anne Arundel Community College does not guarantee licensure, the opportunity to sit for a licensure examination, certification or employment in the relevant health care occupation. Students may be automatically denied admission or, if enrolled, dismissed from the program if they have not been truthful or have provided inaccurate information on the application or on any other form or submission. Students who have questions or concerns are encouraged to contact the Health Sciences Admissions Office at healthsciencesadmissions@aacc.edu. * twithstanding the statements herein regarding urine drug screens, as of September 2010, only certain programs will be requiring drug screening. AACC shall inform students which programs presently require them. However, AACC, at any time, has the right, upon notice, to require any and all students and any and all programs to comply with drug screening.

3 MEDICAL LABATY TECHNICIAN PROGRAM FALL 2018 Application Deadline April 15, 2018 Program Application DEMOGRAPHIC INFMATION (Please print) Last Name First Name Middle Address City State Zip Code County of Residence Last 4 digits of social security # College ID #: The mailing address you provide will be your address of record. It is your responsibility to notify the Health Sciences Office of name, address and phone number changes during the application process. Home Phone Cell Phone Work Phone AACC Address Required other is Admission/Academic Requirement Checklist By signing below, I agree/understand the following: 1. I have an active admission status at AACC and am in Good Standing (2.0 GPA>) with the college. 2. All admission requirements, including prerequisites, must be completed by the application deadline. 3. I must submit final official transcripts from previously attended colleges from which I am transferring courses toward the Medical Laboratory Technician program by the stipulated deadline. International students must submit official transcript evaluation report from ECE or WES to verify/authenticate college transcripts by the stipulated deadline. 4. Photo copy of driver s license or other government-issued photo I.D., or AACC photo I.D. is attached. SIGNATURE: DATE:

4 Please answer the following questions: Math and English Eligibility ADMISSION/ACADEMIC REQUIREMENTS I have demonstrated English eligibility and am eligible for ENG 111, ENG 115 or ENG 121 Information Session I have demonstrated eligibility for MAT 137 College Algebra. I have attended a MLT Information Session. Date: Information Sessions can also be viewed online. Please visit: INTERNATIONAL STUDENTS Have you submitted an official transcript evaluation report from ECE or WES to verify/authenticate your high school and/ or college transcripts to the records office? Agency Used: GENERAL EDUCATION COURSES Please complete the following information (if applicable). COURSE GRADE CREDITS Human Biology 1 BIO 231 A & P 1 BIO 233 COLLEGE WHERE COMPLETED TERM AND YEAR COMPLETED General Microbiology BIO 223 General Chemistry CHE 111 Comp & Intro to Literature 1 ENG 111 Comp & Intro to Literature 1 for n-native Speakers ENG 115 Comp and Literature ENG 121 Computing and Information Technology (formally CSI 112) CTA 100 Theories and Applications of Digital Technology (formally CSI 113 & CTA 103) CTP 103 *College Algebra MAT 137 Introduction to Sociology SOC 111 Fund. of Oral Communication COM 111 Fund. of Oral Communication For n-native Speakers COM 116 This course has a prerequisite of BIO 101. *MAT 121,131,141,142,151or 191 can be used to satisfy this requirement.

5 BACKGROUND INFMATION Submit explanation of questions for which you answer "yes" and provide documents relating to your answer in a sealed envelope attached to this application. Attention: Tammie Neall Do not write explanation(s) on the application. Were you ever disciplined for any academic or behavior/conduct issue by any college, university, or any other educational institution after High School including, but not limited to, probation, dismissal, suspension, disqualification, or imposition of a failing grade as a disciplinary sanction? If your answer is yes provide a written explanation and all relevant documents relating thereto. Have you ever been convicted of a crime, driving while intoxicated or impaired (either by alcohol or drugs), had your driving privileges suspended or revoked, and/or are there any pending charges regarding any of the above? If your answer is yes provide a written explanation and all relevant documents relating thereto. Have you ever surrendered your driver's license or had such license suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto. Have you ever surrendered a professional license, certification or registration, or had one restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto. Have you ever been placed on professional probation, had conditions or limitations placed on your ability to work even if your license had not been restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto. Have you ever had your clinical privileges at any office or facility restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto. NOTE: Licensing boards for certain health care occupations, including Medical Laboratory Technician, may deny, suspend, or revoke a license or may deny the individual the opportunity to sit for an examination even if the individual has completed all program course work, if it is determined that an applicant has a criminal history or is convicted or pleads guilty or nolo contendere to a felony or other serious crime. If applicable, it is recommended to contact national certifying boards for your program of interest. I certify that the information on this application is true and accurate to the best of my knowledge. I am aware that falsification or misrepresentation may result in being denied admission, or if enrolled, dismissed from this program. I understand that final acceptance into the Medical Laboratory Technician program shall be contingent upon satisfactory completion of a criminal background check and satisfactory completion of a health examination record. Signature: Date: PRINT NAME: tice of ndiscrimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, or Maryland Relay 711, 72 hours in advance to request most accommodations. Requests for sign language interpreters, alternative format books or assistive technology require 30 days notice. For information on AACC s compliance and complaints concerning sexual assault, sexual misconduct, discrimination or harassment, contact federal compliance officer at or complianceofficer@aacc.edu or Title IX coordinator at , or Maryland Relay 711.

6 WRITTEN STATEMENT Submit a written statement consisting of a minimum of two paragraphs explaining why you plan to pursue the Medical Laboratory Technician Profession. te: This is for informational purposes only and does not affect the admission process. Name: Date:

7 Anne Arundel Community College MLT Program 101 College Parkway Arnold, Maryland / Records and Registration Office / SSVC 140 VERIFY: Fall / Fax / records@aacc.edu / / MyAACC ADDRESS VERIFICATION F HEALTH SCIENCES APPLICANTS Directions: This form must be completed entirely and documents submitted as part of the health sciences program application process. If you the student support yourself, provide a minimum of two of the documents listed below in your name, at current resident address that are dated three months prior to the application deadline date. If for the most recent 12 months, you, the student, have resided in Anne Arundel county, but are supported by someone in another Maryland county or state, provide a minimum of two of the documents listed below in your name, at current resident address that are dated three months prior to the application deadline date. If for the most recent 12 months, another person(s) has provided one-half or more of your financial support, provide a minimum of two documents listed below in your supporter s name, showing current resident address that are dated three months prior to the application deadline date. In addition, you will need to provide one document from the list below in your name showing your current resident address and dated three months prior to the application deadline date in addition to the two documents from your supporter. The supporter must also complete the information requested in Section B. Military Personnel Only: Complete this form with a copy of your military ID (also dependent ID, if spouse or dependent), copy of orders, and a copy of housing assignment, lease, deed or utility bill showing your resident address. Application Term: FALL 2018 Application Deadline: April 15, 2018 Example: If the application deadline date is April 15, 2018, documents must be dated on or before January 15, Acceptable Documents: Maryland Driver s License Voter Registration Card Copy of Deed of Trust or Signed Lease Maryland Withholding Form MW 507 (not U.S. W-2) Maryland Income Tax Return (not U.S.) Utility Bill: gas, electric, water, phone, cable, etc. Vehicle Registration Card The college reserves the right to request additional information and documentation as necessary. SECTION A TO BE COMPLETED BY STUDENT 1. Student Name Student ID or SSN (Last 4 digits) 2. Resident Address City, State, Zip County Day Phone: Evening: 3. Dates of occupancy at above address Own Rent Previous Address City, State, Zip How long did you live at this previous address?

8 5. Are you registered to vote? County and State 6. Do you possess a valid driver s license? If yes, in what state issued? County Date of Issuance 7. Do you own a motor vehicle? If yes, in what state issued? County Date of Issuance 8. Do you have the use of another person s motor vehicle? If yes, provide name Relationship to student 9. Are you paying Maryland income tax for this year on all earned income? If yes, which county? 10. List where you have filed income tax returns for the past two (2) years. State County State County 11. If employed, is Maryland income tax currently being withheld? If yes, which county? 12. For the most recent 12 months, has another person(s) provided one-half or more of your financial support? * * If the answer to question 12 is, SECTION B (next page) must be completed by your supporter. Additional information: The college reserves the right to request additional information and documentation if necessary. I CERTIFY THAT THE INFMATION CONTAINED HEREIN IS CRECT TO THE BEST OF MY KNOWLEDGE. Signature of Student (required) OFFICE USE ONLY Date ACCEPTABLE DOCUMENTS: MILITARY / BRAC WAIVER: 1. MD driver s license 1. Military ID (& Dependent ID, if spouse or dependent) 2. MD income tax return (not U.S.) 2. Copy of orders 3. Voter registration card 3. Copy of housing assignment, lease, deed, or 4. Vehicle registration utility bill showing resident address 5. Utility bill showing home address 6. Copy of deed of trust or signed lease 7. MD withholding form MW 507 (not U.S. W-2) STATUS OF RESIDENT ADDRESS Anne Arundel county Other MD county Out-of-State Term & Year

9 Authorized Signature Date SECTION B TO BE COMPLETED BY SUPPTER IF ANSWER TO QUESTION 12 IN STUDENT SECTION IS YES 1. Name of Supporter Relationship to Student 2. Supporter s Address City, State, Zip County Day Phone: Evening: 3. Dates of occupancy at above address Own Rent 4. Previous Address City, State, Zip How long did you live at this previous address? 5. Are you registered to vote? County 6. Do you possess a valid driver s license? If yes, in what state issued? County Date of Issuance 7. Do you own a motor vehicle? If yes, in what state issued? County Date of issuance 8. Do you have the use of another person s motor vehicle? If yes, provide name Relationship to student 9. Are you paying Maryland income tax for this year on all earned income? If yes, which county? 10. List where you have filed income tax returns for the past two (2) years State County 2014 State County 11. If employed, is Maryland income tax currently being withheld? If yes, which county? Additional Information: The college reserves the right to request additional information and documentation if necessary. I CERTIFY THAT I HAVE SUPPTED THE ABOVE-NAMED STUDENT F THE MOST RECENT 12 MONTHS AND THAT THE INFMATION CONTAINED HEREIN IS CRECT TO THE BEST OF MY KNOWLEDGE. Signature of Supporter Date tice of ndiscrimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, or Maryland Relay 711, 72 hours in advance to request most accommodations. Requests for sign language interpreters, alternative format books or assistive technology require 30 days notice. For information on AACC s compliance and complaints concerning sexual assault, sexual misconduct, discrimination or harassment, contact the federal compliance officer and Title IX coordinator at , complianceofficer@aacc.edu or Maryland Relay 711.