Fillable Hitmapplication Health Informaton Technology and Management

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Hitmapplication Health Informaton Technology and Management

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LARAMIE COUNTY COMMUNITY COLLEGE
HEALTH INFORMATION
TECHNOLOGY AND
MANAGEMENT
APPLICATION PACKET
Page 1 of 6
TM
Health Information Training and Management Program
Participant Application Form
A
PPLICANT
D
ATA
Applicant Name:
F
IRST
:
M
IDDLE
(I
NITIAL
):
L
AST
:
Social Security Number:
LCCC Student ID:
Address:
City, State, Zip:
Phone:
Email Address:
Date of Birth (mm/dd/yyyy):
Sex:
Male Female
Is applicant currently employed:
Yes No
If yes, employment status:
Full-time Part-time
If yes, name of employer:
Employer’s mailing address:
City, State, Zip:
Current hourly wage:
Veteran:
Yes No
Trade Adjustment
Yes No
1
st
Generation College Student:
(Did your parents complete a
College degree?)
Yes No
Applicant is a U.S. Citizen or
Legal Resident
I certify that the above information is correct to the best of my knowledge, and I agree that this
information may be released to the Consortium for Healthcare Education Online (CHEO).
Applicant Signature:
Date:
I certify that the above information is correct to the best of my knowledge. I agree to protect the
confidentiality of the applicant’s information and to use the information for authorized statistical
purposes only.
HITM Program Representative:
Date
Page 2 of 6
E
XIT
I
NFORMATION
–
F
OR
O
FFICE
U
SE
O
NLY
Date of Program Exit:
Was program successfully completed? Yes No
If no, reason for leaving:
Is participant employed? Yes No
If yes, name of employer:
Mailing Address:
City, State, Zip:
Start Date:
Hourly Wage: $
Instructions
All applicants must complete an Application Packet. Failure to provide the requested information will result in
disqualification from participating in the program.
Participant files must be kept for 4 years following program exit date.
Laramie County Community College
Attn: HITM Program
1400 E College Drive
Cheyenne, WY 82007
Page 3 of 6
GOALS
Demonstrating commitment to our program is one of the single greatest
areas of importance we look at when determining your suitability for
HITM. Please take time to seriously consider your goals and desired
outcomes after graduating from our professional training. “A goal not
written is only a wish.”
1. Why are you interested in HITM?
2. What are your career goals?
3. What are your educational goals?
4. What are your personal goals?
5. How much time are you willing to commit to studying for your classes?
Applicant Signature: ___________________________________ Date: _____________________
Page 4 of 6
HEALTH INFORMATION TECHNOLOGY & MANAGEMENT
ESSAY
Name: _______________________________________ Date: ___________________
In order for HITM to determine your motivation and commitment to the program, we would like you to
take a moment to write a paragraph or two explaining why you should be considered for enrollment into
the program. Use additional paper if necessary. Items to include in your essay are as follows:
1. What do you know about the career training you are pursuing and why are you applying for this
career path?
2. Why do you feel you are ready to enroll in the Health Information Technology & Management
program?
3. What is your commitment level to participate? Explain your level of commitment to the program.
4. How do you feel
you
can obtain your goals through our training?
Page 5 of 6
CHECKLIST
I submitted an LCCC application for Admissions
Date: _________________________________
Official Transcripts were requested on the following dates:
Date: ______________________ Institution: ______________________________________
Date: ______________________ Institution: ______________________________________
Date: ______________________ Institution: ______________________________________
Date: ______________________ Institution: ______________________________________
Student transcripts are enclosed with this application.
I understand that it is my responsibility to furnish all the required paperwork and that an
incomplete application will be ineligible for consideration.
________________________________________________________ ______________________
Signature Date
Please send this completed application packet to:
Health Information Technology & Management Program
Laramie County Community College
1400 E College Drive
Cheyenne, WY 82007
307.432.1686 lccc.wy.edu
Page 6 of 6
PRS PDF 1700 2/14
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Completed 17 February 2020

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