APPLICATION FOR HEALTH SCIENCES PROGRAM

Updated as of 07/01/15 . Houston Community College System seeks to provide equal educational opportunities without regard to race, color, religion, na...
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Updated as o f 07 /01/15

APPLICATION FOR HEALTH SCIENCES PROGRAM

CONTACT INFORMATION Full Name: Phone #: Address: City: Emergency Contact Name:

HCC ID #: E-mail:

Alternate Phone #:

State: Phone #:

ZIP Code:

PROGRAM OF CHOICE Computed Tomography

Human Service Technology

Occupational Therapy Assistant

Dental Assistant

Medical Assistant

Pharmacy Technician

Dental Hygiene

Medical Laboratory Technician

Pharmacy Technician (Retail MSA)

Diagnostic Medical Sonography

Nuclear Medicine Technology

Physical Therapist Assistant

Health Information Technology

Nursing – CNA-LVN Transition

Radiography

Health Care Career Academy – Phlebotomy

Nursing – LVN

Respiratory Therapy

Health Care Career Academy – Sterile Processing

Nursing – LVN-RN Transition

Surgical Technology

Histologic Technician

Nursing – RN

APPLICATION SEMESTER Fall, Year

Spring, Year

Summer, Year

CURRENT HEALTH SCIENCE PROFESSIONAL LICENSE OR CERTIFICATE Type: Number:

State: Expiration Date:

HEALTH CARE EMPLOYMENT HISTORY Employer: Position Title: Job Description: Employer: Position Title: Job Description:

Dates of Employment: Reason for Leaving: Dates of Employment: Reason for Leaving:

PREVIOUS COLLEGES / UNIVERSITIES ATTENDED (LIST MOST RECENT FIRST) Name of College/University: Type of Degree Completed/Major: Name of College/University: Type of Degree Completed/Major:

GPA: Semester Hours Completed: GPA: Semester Hours Completed:

SIGNATURE The information I have provided is complete and correct to the best of my knowledge. Applicant Signature:

Date:

Advisor Signature:

Date:

Note: Background checks and drug screenings are performed on all accepted s tudents. Clinical placemen t will be contingen t upon the r esults of the background check. Applicants w ho have been convicted of a felony must contact the a ppropriate credentialing agency to de termine eligibility.

Houston Community College System seeks to provide equal educationa l opportun ities witho ut regard to race, color, religion , na tional orig in, sex, age, or d isability.