Fillable DIALYSIS APPLICATION FALL 2020 (Wilson Community College)

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DIALYSIS APPLICATION FALL 2020 (Wilson Community College)

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DIALYSIS APPLICATION ∙ FALL 2020
Admission into the Dialysis Technician program is by application, and only completed applications will be
accepted. The schedule for FALL 2020 semester is available on the reverse side. Registration fee is $224
which includes: $180 registration, $5 technology, $15 security, $2 accident insurance, $16 malpractice
insurance, and $6 CPR eCard. CPR is required for clinical – must be AHA Health Care Provider.
Training includes class, lab, and clinical experiences. The course is designed to prepare individuals with
the theoretical, technical, and clinical skills needed to maintain equipment and provide patient care to
those being treated for chronic renal diseases. Class format includes lecture, laboratory, and clinical
activities. Successful completion prepares individuals for employment as a dialysis technician in hospitals,
renal dialysis facilities, and clinics. After one year of work experience, individuals may be eligible to sit for
national certification as a Clinical Hemodialysis Technician.
The Division of Continuing Education in partnership with DaVita Dialysis supports the responsibilities of the
Student Internship Program established by DaVita. Students are responsible for completing the online
background screening through HireRight and eScreen. Students must complete the drug screen through
eScreen within 72 hours of receiving the email. Internship (clinical experience) with DaVita cannot start
until the screenings have been successfully completed. It is important for the student to go online to
provide the requested information upon receipt of the emails from HireRight and eScreen.
Students must respond to all emails from DaVita within 72 hours. Students are not financially responsible
for the drug test or criminal background check. Failure to complete all the requirements listed by DaVita
will result in the student not being able to attend the clinical portion of the Dialysis program.
APPLICATION REQUIREMENTS:
• Complete the Dialysis application on reverse side. Application can also be downloaded from the
wilsoncc.edu website; Continuing Education, Health Occupations page.
• Submit completed application to mkillette@wilsoncc.edu or to the Continuing Education office on
campus, B105.
• Copies required of the following:
• High school diploma or equivalent
• North Carolina picture ID (example: driver’s license)
• Proof of the following immunizations:
• One TB skin test within the past twelve (12) months of class start date
• Two MMR (Mumps, Measles, Rubella) injections
• Three Hepatitis B (at least the first injection prior to the start date is required)
• Varicella injection or Titer (blood test to prove immunity to chicken pox)
• Tdap (within the past 10 years)
• Flu vaccine – starting September 2020
It is the student’s responsibility to obtain copies of the required immunization records.
Keep the original record and SUBMIT COPIES ONLY.
TEXTBOOKS REQUIRED:
• Dialysis - Core Curriculum for Dialysis Technicians (6
th
edition) – (Approximately $50)
• American Heart Association Textbook for CPR - (Approximately $20)
REQUIRED PRIOR TO CLINICAL ROTATIONS:
UNIFORMS: Teal top and white pants, white lab coat, and white, closed-toe shoes. Skirts and/or dresses
must be approved by the Instructor prior to clinical rotation.
DIALYSIS APPLICATION for FALL 2020 ▪ Section # 36129
August 18 – December 1 ▪ 9 AM – 1 PM ▪ Tuesday & Thursday of each week ▪ Building: G ▪ Room: 109
Clinical Hours: 6 – 8:30 AM and 10 AM - 12:30 PM
(Register by August 17)
Applications are now available on the WCC website or in the Continuing Education Office, B105. Students
wishing to have applications approved are welcome to call 252-246-1325 for questions regarding the
approval process. Early registration begins on July 6, 2020. Classes fill up quickly so early registration is
encouraged. Completed applications are accepted on a first come first served basis. The $224 fee is due
at the time of registration. The registration and approval process will continue until the day before class or
until the class is full.
NAME: Last: First: Middle Initial:
ADDRESS: City/State: Zip:
PHONE: Home: Cell:
EMAIL ADDRESS: NC ID:
BIRTHDATE: Month Day Year SEX: ❑ Male ❑ Female
RACE: ❑ White ❑ Black ❑ American Indian ❑ Hispanic ❑ Asian ❑ Other
EMPLOYMENT: ❑ Unemployed ❑ Part-Time ❑ Full-time EMPLOYER:
CAREER PLANS:
DO YOU HAVE PREVIOUS EXPERIENCE IN THE HEALTH FIELD? ❑ Yes ❑ No
IF YES, PLEASE LIST:
AGREEMENT
I have attached all required copies to my application; I have read, understand and agree to all stated
requirements of the Dialysis program; I understand the required clinical dress code, and agree to comply
upon acceptance; I understand this is an application only and does not constitute acceptance into the
program; and understand I will be dismissed from the program if documented as verbally or physically
abusive to college administration, clinical site staff, patients, or visitors.
SIGNATURE: DATE:
If any facility prohibits the student from participating in the clinical experience, the student will be
dismissed due to an inability to progress and complete the program.
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Completed 26 July 2020

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