ORANGE COUNTY COMMUNITY COLLEGE OFFICE OF ADMISSION
MIDDLETOWN, NEW YORK 10940
Fall 2011 Medical Laboratory Technology Admissions Eligibility Form
This form must be filled out by students wishing to be considered for entry into the Medical Lab Technology Program in Fall 2011
and returned to the Admissions Office by February 1, 2011 for consideration.
Name (Please print legibly):_________________________________________________ Student ID#: A
Mailing Address:________________________________________________________________
City:_________________________State:_____Zip Code:________ Legal County of Residence:__________________
Phone Number:________________________ E-Mail:______________________________
Date of Birth:_________________
Have you ever been enrolled in a Health Professions program at an Associate’s degree level or higher either at SUNY Orange or
another college? Yes No Program:_______________________________
If yes, did you successfully complete the program? Yes No
Transcripts from all institutions will be reviewed as part of the admissions process. Please list all colleges previously attended:
____________________________________________________________________________________________________________
Admissions Requirements
Academic Requirements:
High school diploma or GED.
Eligible to take Freshman English I (ENG 101).
Eligible to take Elementary Algebra (MAT 101) or have successfully completed Developmental Algebra (MAT 020)
Students must attain a minimum cumulative GPA of 2.0.
Department Specific Requirements:
Attendance at a Medical Lab Technology pre-admission orientation. At this orientation, students will receive and sign off on
information pertaining to health forms, drug testing, and criminal record policies. Orientation dates are available online at
www.sunyorange.edu/admissions/healthforms.shtml
.
Selection Process
Students will be considered for admission into this program based on the completion of all mandatory eligibility requirements,
highest combination of cumulative GPA and credits completed towards the program (see reverse), and seats available. Students
must meet all of the above requirements to be considered for admission into the program.
All Medical Laboratory Technology Admissions Eligibility Requirements must be completed before February 1
st
in order for a
student to be considered for acceptance into the program for the fall semester.
Student Certification and Signature (please check one of the following):
I have attended a pre-Admissions Orientation within 3 years of my planned program start date (Fall 2008 semester or later).
I plan to attend/have attended a pre-Admissions Orientation this year. Include date attended/plan to attend (mo/yr)____________
My signature acknowledges that I have read and accept the admissions requirements listed above, and that all of the information
provided is accurate and complete. (When emailing this form, you acknowledge the requirements by typing your full name and date.)
Student Signature
Date:
For Office Use Only: Accept _________Alt_______ Checklist_______ Low Cum_______ No Deposit _____ Declined ____
Dept Chair/Designee Signature Date:
Admissions Signature
Date:
*Though not admissions requirements, completing the courses below will enhance your eligibility
Print Form
(26 credits): Please be aware that if you have not taken the course within the timeframe listed below, you must retake the course.
ENG 101 Freshman English I (3 cr.)
ENG 102 Freshman English II (3 cr.)
Any Social Science (3 cr.)
Any Social Science (3 cr.)
CHM 103 Applied Chemistry I (3 cr.) – must have been completed within 10 yrs of program entry
CHM 104 Applied Chemistry II (3 cr.) – must have been completed within 10 yrs of program entry
MAT 1-- Any Mathematics (3 cr.)
Elective (3 cr.)
PES 100 Concepts of Physical Wellness (1 cr.)
PES --- Physical Ed. (Activity Course) (.5 cr.)
PES --- Physical Ed. (Activity Course) (.5 cr.)
For Office use only:
_______ HS Diploma/GED
English Requirement
Math Requirement
CumGPA is 2.0 or higher
_______ Pre-Admission Orientation Complete
_______ Total Credits
_______ CumGPA
_______ Score
Checklist Items:
Developmental Course Requirement
Course Requirement
Course Grade Requirement
Age of Course
Low GPA
Incomplete Application
Not Enrolled
Late Application
Pre-Admission Orientation
Rev. 8/10