Fillable Phlebotomy Technician Program Application (Anne Arundel Community College)

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Phlebotomy Technician Program Application (Anne Arundel Community College)

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Phlebotomy Technician
Program Application
Applications Available: Rolling Admissions
ADMISSION REQUIREMENTS
To become a candidate for selection to the Anne Arundel Community College Phlebotomy Technician Program, please
complete and email the application to vbardhi@aacc.edu
. Alternatively students may mail their application to
Anne Arundel Community College
ATTN: School of Health Sciences, FLRS 112
101 College Parkway
Arnold, MD 21012
Students will be admitted to the Phlebotomy course sequence on a rolling admission basis. Students will apply for the
Phlebotomy program only after meeting all academic and admission criteria. Applications will not be processed if
incomplete. Incomplete applications will be returned to the student and can be resubmitted once they are complete. A
future seat will be slotted for them once the student meets the criteria for admission.
To be considered for conditional acceptance, the applicant must meet the following criteria:
• Attend an information session. Please visit
http://www.aacc.edu/apply-and-register/credit-application/health-science-
applicants for dates and times. Virtual real-time information sessions will be available during summer and fall 2020.
Admission and selection information will be reviewed at the information session.
• Demonstrate eligibility for ENG 101/ENG 101A.
• Must be 18 years of age or older by the first day of class.
• Official transcripts, if applicable. Official transcripts are to be received by AACC’s Records and Registration office
in the sending institution’s original sealed envelope or through acceptable electronic method. Visit
https://www.aacc.edu/apply-and-register/credit-application/apply/transfer-credit-to-aacc/
for details.
Eligible applicants will receive a selection packet assigning them to one of the following categories:
o Conditional Acceptance: Applicants who have met the academic and admission requirements and have been
selected into the Phlebotomy program. With the selection packet, conditionally accepted students will receive the
health examination record, criminal background check and CPR instructions to be completed by a designated
deadline. Conditional Acceptance candidates who do not meet this deadline will not be considered for admission
and the next person on the list will be contacted.
o Wait List: Qualified applicants not initially selected for Conditional Acceptance will be placed on a waitlist in order
received and notified of selection when a seat becomes available. Waitlisted applicants not given a seat for the
semester for which they applied will automatically be given a seat in the next class.
Final acceptance into the program will be contingent upon satisfactory completion of a criminal background check,
health examination record and submission of a copy of the required CPR card.
IMPORTANT INFORMATION
1. Direct all inquiries regarding the application process to Valerie Bardhi via email at vbardhi@aacc.edu. Following
review of all applications, students will receive a letter regarding the status of their application.
2. All Health Sciences students who are offered admission and/or clinical placement will be required to submit to a
complete criminal background check and urine drug screen. All student applicants’ final acceptance in the program
shall be contingent upon satisfactory completion of a criminal background check and of a urine drug screen.*
All letters of acceptance shall state that the acceptance is conditional and contingent on submission to a criminal
background check and urine drug screen—as may be required by the program--that results in satisfactory reports. If
an accepted student tests positive for an illegal or un-prescribed drug, the student shall be denied admission or
terminated from any Health Sciences program.
Separate, additional criminal background checks and urine drug screens may be required by clinical sites prior to
placements. Students with an unsuccessful background check or urine screening who are denied by a clinical site
that is required to meet program competencies shall be dismissed from the program and their registrations shall be
withdrawn from courses related to the program of study. If the student tests positive for an illegal or un-prescribed
drug, the student shall be denied admission or terminated from any Health Sciences program even if a denied
placement was not required to meet program competencies. Successful reports of criminal background checks and
urine drug screens do not assure eligibility for specific clinical site placement, program completion, and/or eligibility
to sit for professional licensure/board examinations.
Students are reminded that licensing boards for certain health care occupations and professions may deny,
suspend, or revoke a license or may deny the individual the opportunity to sit for an examination even if the
individual has completed all program course work if it is determined that an applicant has a criminal history or has
been convicted of, or pleads guilty, or pleads nolo contendere or the like to a felony or other serious crime.
Successful completion of a Health Sciences program of study at Anne Arundel Community College does not
guarantee licensure, the opportunity to sit for a licensure examination, certification or employment in the relevant
health care occupation.
Students may be automatically denied admission or, if enrolled, dismissed from the program if they have not been
truthful or have provided inaccurate information on the application or on any other form or submission. Students
who have questions or concerns are encouraged to contact the Health Sciences Admissions Office at
healthsciencesadmissions@aacc.edu
.
* Notwithstanding the statements herein regarding urine drug screens, as of September 2010, only certain
programs will be requiring drug screening. AACC shall inform students which programs presently require
them. However, AACC, at any time, has the right, upon notice, to require any and all students in any and all
programs to comply with drug screening.
G:\ALHEALTH\HDrive\AHCOMMON\TDN\Applications 2020-2021 IC Approved FINAL\PDFs for the webPhlebotomy Aplication IC Approved FILLABLE FORM. 6.29.2020
PHLEBOTOMY TECHNICIAN PROGRAM
Rolling Admissions
PROGRAM APPLICATION
Students are admitted to the Phlebotomy Technician Program on a rolling admission basis. Incomplete applications
will be returned to the student and can be resubmitted only after they are complete. Students need only apply once
to the program, provided their application is complete. A future seat will be slotted once the applicant meets the
criteria for admission. Please print clearly. Submit completed application to vbardhi@aacc.edu
or via mail to Anne
Arundel Community College, ATTN: School of Health Sciences, FLRS 112, 101 College Parkway, Arnold, MD
21012.
DEMOGRAPHIC INFORMATION (Please print)
Last Name
First Name
Middle
Address
City
State
County
Last 4 digits of social security #
College ID #
The mailing address you provide will be your address of record. It is your responsibility to notify the Health Sciences Office
of name, address and phone number changes during the application process.
Home Phone
Cell Phone
Work Phone
AACC Email Address – Required No other email is acceptable
@mymail.aacc.edu
Admission/Academic Requirement Checklist
By signing below, I agree to and understand the following:
1. I attended a mandatory Phlebotomy Technician Program information session or a virtual real-time session during
summer 2020 or fall 2020.
2. I am ENG 101/ENG 101A eligible.
3. I am 18 years of age or older.
4. If information is missing from my application or file (including transcripts), it will NOT be processed and will be
returned to me. Incomplete applications will NOT be considered.
5. I understand that by filling in my name below, it will be considered my signature.
SIGNATURE:
DATE:
ADMISSION/ACADEMIC REQUIREMENTS
Please answer the following questions:
English Eligibility
Yes No I have demonstrated English eligibility and am eligible for ENG 101/ENG 101A.
Information Session
Yes No I have attended a Phlebotomy Technician Program information session. Date:
NOT
E: Licensing boards for certain health care occupations may deny, suspend, or revoke a license or may deny the
individual the opportunity to sit for an examination even if the individual has completed all program course work, if it is
determined that an applicant has a criminal history or is convicted or pleads guilty or nolo contendere to a felony or other
serious crime. If applicable, it is recommended to contact the national certifying boards for your program of interest.
I certify that the information on this application is true and accurate to the best of my knowledge. Falsification or
misrepresentation may result in being denied admission, or if enrolled, dismissed from this program. I understand that final
acceptance into the program shall be contingent upon satisfactory completion of a criminal background check and of a
health examination record.
I understand that by filling in my name below, it will be considered my signature.
Signature: Date:
Print Name:
AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, 410-777-2306 or Maryland Relay 711,
72 hours in advance to request most accommodations. Requests for sign language interpreters, alternative format books or assistive technology require 30 days’
notice. For information on AACC’s compliance and complaints concerning sexual assault, sexual misconduct, discrimination or harassment, contact the federal
compliance officer and Title IX coordinator at 410-777-1239, complianceofficer@aacc.edu
or Maryland Relay 711.
G:\ALHEALTH\HDrive\AHCOMMON\TDN\Applications 2020-2021 IC Approved FINAL\Word copies\Phlebotomy Application Rolling IC Approved 6.25.2020.doc
BACKGROUND INFORMATION
Submit explanation of questions for which you answer "yes" and provide documents relating to your answer in a
sealed envelope and emailed to tdneall@aacc.edu or mailed separately to address on first page of this application,
ATTN: Tammie Neall.
Do not write explanation(s) on the application.
Yes
Were you ever disciplined for any academic or behavior/conduct issue by any college, university, or any other
educational institution after high school including, but not limited to, probation, dismissal, suspension,
disqualification, or imposition of a failing grade as a disciplinary sanction? If your answer is yes provide a
written explanation and all relevant documents relating thereto.
Have you ever been convicted of a crime, driving while intoxicated or impaired (either by alcohol or drugs),
had your driving privileges suspended or revoked, and/or are there any pending charges regarding any of
the above? If your answer is yes provide a written explanation and all relevant documents relating thereto.
Have you ever surrendered your driver's license or had such license suspended or revoked? If your answer is
yes provide a written explanation and all relevant documents relating thereto.
Have you ever surrendered a professional license, certification or registration, or had one restricted, suspended
or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto.
Have you ever been placed on professional probation, had conditions or limitations placed on your ability to
work even if your license had not been restricted, suspended or revoked? If your answer is yes provide a
written explanation and all relevant documents relating thereto.
Have you ever had your clinical privileges at any office or facility restricted, suspended or revoked? If your
answer is yes provide a written explanation and all relevant documents relating thereto.
Please review prior to submitting this application. This application must be completed in its entirety.
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
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Completed 22 July 2020

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