Fillable Medical Assisting Application Medical Assisting Application

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Medical Assisting Application Medical Assisting Application

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File type: PDF

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Medical Assisting Application
Incomplete Applications will not be processed
March 1 – May 1
Name: ___________________________________________________________________________________
Last First Middle Initial
PCC Lancer ID#: _________________________________
Address: _________________________________________________________________________________
City: ________________________________________________ Zip: ________________________________
Cell Phone #: __________________________ Home Phone #: ____________________________________
Email: ___________________________________________________________________________________
Students will only be notified of their status by email. Please type carefully.
One
official
transcript of ALL colleges, including PCC, and high school/GED equivalency report must be
submitted with this application. Students who have an Associate Degree or higher do not need to submit a
U.S. High School transcript/GED/Foreign Equivalency Report. A second official transcript must be sent to
the Office of Admissions upon acceptance to the program.
GED Foreign Equivalency Report
Associates Bachelors
Official U.S. High School transcript
Your last name while in High School:
College degree(s) received:
List all colleges attended:
(1)
(2)
(3)
(4)
Are you a U.S. Veteran or spouse of a U.S. Veteran?
Yes (please provide a copy of your DD214.
Spouses must also submit a copy of the marriage
certificate
).
No, I am not a U.S. Veteran or spouse of a U.S. Veteran.
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*Priority admission is given to students seeking the full-time Medical Assisting Certificate of Achievement
and have completed Medical Terminology, Anatomy 25 or Physiology 100 (thru 2019), and Computer
Keyboarding or equivalent. *
Please select one program only. Indicate part-time or full-time for Administrative or Billing options
Medical Assisting Certificate of Achievement (clinical/administrative) (full-time option only
Medical Office Administrative Certificate of Achievement (part-time or full-time option)
Medical Office Insurance Biller Certificate of Achievement (part-time or full-time option)
Course
College
Course Title
and Number
Units
Grade
Term/Year
Medical Terminology
(MA 115) – 3 units
Anatomy 25 or
Physiology 100
(accepted until 2019)
BUSN 2601A
Computer Keyboarding A
or equivalent
Upon selection, applicants are required to complete a health clearance, CPR Provider Level BLS (basic life
support) course through (American Heart Association), first aid course, and background check to attend
clinical practicum, which is required for program completion (clinical students only). A social security
number could be required by the practicum site, if employment opportunities are made available upon
completion of the practicum. Details regarding these clearances will be provided to selected candidates
during orientation. Students who have questions or concerns about the background check are encouraged
to contact the Medical Assisting Program Director.
Note:
Submission of a completed application packet does not guarantee acceptance.
My signature below indicates that I have provided true and accurate information on this
application and that I understand final acceptance to the program will be based on program
criteria and space availability.
Signature Date
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Additional Selection Criteria
Check off
any additional items you are submitting with your application. Remember to include
documentation for any item checked off.
Documentation Included
Documentation Required
High School Diploma/GED
Must be posted to official U.S. transcripts
BS/BA Degree
Must be posted to official U.S. transcripts
AA/AS Degree
Must be posted to official U.S. transcripts
Foreign Equivalency Report
Must be posted to official U.S. report
Veteran Status
Copy of DD214 Honorable Discharge Required
*Marriage Certificate (if spouse)
Applications with
all
required official transcripts and supporting documentation may be submitted to
the:
Community Education Center
School of Allied Health Sciences - Attn: Medical Assisting Program
3035 East Foothill Blvd. – B6
Pasadena, CA 91107
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Medical Assisting Application Medical Assisting Application

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Completed 1 November 2019

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