Fillable Pre-Admission Application Packet

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Pre-Admission Application Packet

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The Pre-Admission Application Packet form is 6 pages long and contains:

  • 4 signatures
  • 14 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Collin County Community College District

BROWSE COLLIN COUNTY COMMUNITY COLLEGE DISTRICT FORMS

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Nurse Aide, Nursing Refresher (RN),
EKG, and Dental Assistant
Pre-Admission Application
Page 1 of 7
November, 2018 – PreAdmission Application
Student,
Thank you for your interest in our continuing education healthcare courses. Below you will find pre-admission
information relevant to our Nurse Aide, Nursing Refresher (RN), Electrocardiography (EKG), and Dental Assistant
training. This application packet must be completed and returned to the CE Health Sciences department at the
Courtyard Center prior to registering for classes. Submit copies only, documents will not be returned. We will not be
able to provide a copy back to you after submission, so please keep your originals.
Please return completed application forms, vaccine printout from ArcPoint labs, and copies of your ID and Basic Life
Support Card to the CE Health Sciences Office, Courtyard Center in Plano, Texas between the hours of 8AM and 5PM,
Monday through Friday. If needed, the documents may be faxed to 972.985.3782 or emailed to CEHealthcare@collin.edu.
Applications are reviewed several times a week by the review committee. After the review, students will be emailed with
approval or with a request to submit additional documentation.
Thanks again, and we look forward to working with you on your healthcare career goals!
Sincerely,
The CE Health Sciences Team
Nurse Aide, Nursing Refresher (RN),
EKG, and Dental Assistant
Pre-Admission Application
Page 2 of 7
November, 2018 – PreAdmission Application
Checklist
Step 1:
□ Go to ArcPoint for a background check. See page 7 for detailed instructions. Cost for this service is $45.
□ Go to ArcPoint to submit for a drug test. Map and instructions are on page 7. Cost for this service is approximately
$30.
□ Results of these 2 checks are provided directly to Collin College in about 3 days.
Step 2:
□ All students must submit all vaccine documentation to ArcPoint for verification, not Collin College. See page 7 for
a map and detailed instructions. Cost for this service is $30.
Required vaccines are:
MMR – 2 doses (in accordance with CDC requirements)
or positive titers through bloodwork
Varicella – 2 doses (in accordance with CDC
requirements) or positive titers through bloodwork
Hepatitis B – 2 doses (in accordance with CDC
requirements) or positive titers through bloodwork
Tetanus – 1 dose within the past 10 years
Tuberculosis – negative skin test or chest X-ray within
the past 12 months
Flu – current year’s flu vaccine (Sept-April)
Step 3:
□ Copy the front and back of your Basic Life Support card.
If you do not have a card, please visit http://www.collin.edu/ce/healthsciences/life-support.html as we
offer this course frequently. You will need to register and pay for the course, attend class and pass your
exams to receive your BLS card and be eligible for participation in one of the training programs.
This course must follow American Heart Association guidelines and MUST include a hands-on skills
assessment. Courses that are taken fully online will not be accepted.
Step 4:
□ Complete the application information on page 3, circle the course you want, sign and date the bottom.
□ Read the Waiver, Release & Indemnification Agreement on page 4. Enter your name in the first blank, and
complete the box of information at the bottom of the page.
□ Read the Clinical Rights and Expectations on page 5. Enter the date, sign and print your name at the bottom of the
page.
□ For Dental Assistant students only, complete the Communicable Disease Form on pg 6.
Step 5:
□ Submit all documentation to the CE Health Sciences Department. We need:
Pages 3, 4, and 5 of this application packet, (page 6 for Dental Assistant students)
Vaccine printout from ArcPoint labs,
Copy of State issued ID,
Copy of Basic Life Support card.
These vaccines can be
obtained at your doctors’
office, the county health
department, ArcPoint
labs, and some
pharmacies.
Nurse Aide, Nursing Refresher (RN),
EKG, and Dental Assistant
Pre-Admission Application
Page 3 of 7
November, 2018 – PreAdmission Application
Name: CWID or Birthdate:
Mailing address: City:
Preferred phone:
Other languages:
E-mail address: Course Start Date:
Requested Course (check one): CNA Nursing Refresher (RN) EKG Dental Assistant
By signing below, I agree to the following conditions:
I have attached the required documentation for consideration, including the vaccine printout from ArcPoint Labs.
I have read and understand the rules and regulations of the college and the program and will abide by these as terms of my
continuation in the program.
The information I have given in this application is factual, and I understand that falsification of any required
documentation will result in the denial of my application or removal from class.
I understand that I must obtain and pay for liability insurance prior to attending class. I understand this insurance is NOT
health insurance. This insurance is provided through Collin College and will be charged to my account at the point of
registration. (Fee ranges from $5-$13, depending on date of enrollment.)
I have read and understand the potential for exposure to blood or other potentially infections materials (information
available at http://www.cdc.gov/hepatitis/HBV/index.htm) or exposure to inhalation of airborne microorganisms
(smallpox, tuberculosis, latex…) and I will not hold Collin College liable for any accidental exposure I may experience.
I have read and understand the terms related, and release Collin College and its employees from any liability.
I understand that this type of course/career has specific physical requirements, which may include lifting up to 25 pounds.
I understand that if I don’t successfully complete and pass each requirement for admissions, my application will be
declined.
I understand that enrollment in these courses is limited, and seats will be awarded in date order based on those students
who complete, turn in, and pass all pre-admission requirements.
I understand that I must successfully complete competencies in the classroom portion of my training and maintain at least
90% classroom attendance to pass the course and be eligible for clinicals.
Nurse Aide Students: I understand that I must successfully complete classroom AND clinical components of my
training AND get instructor approval to take the registry exam. Nurse Aide Registry (Nurse Aide students only) (will
be checked prior to approving individuals to ensure that prospective students are not listed on the registry as
unemployable. An individual, who has had a finding of abuse, neglect or misappropriation of patient’s property
entered on the registry, will be prohibited from clinical, taking the competency exam and being issued a certificate of
nurse aide competency (re 42 Code of Federal Regulation, 483 (1)(ii)).)
Signature: _____________________________ Date: ________________
Collin College does not discriminate on the basis of race, color, religion, age, sex, national origin, disability or veteran
status.
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signature
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Nurse Aide, Nursing Refresher (RN),
EKG, and Dental Assistant
Pre-Admission Application
Page 4 of 7
November, 2018 – PreAdmission Application
WAIVER, RELEASE & INDEMNIFICATION AGREEMENT
I, , being of legal age, have voluntarily agreed to participate in an Externship (the
“Externship”) at:______________________________________________________________________ (the
“Facility”). In consideration for being permitted to participate in the Externship, I, acting individually & on behalf of my
children, parents, heirs, successors, assigns, personal representatives & estate, hereby agree as follows:
1. Release from Liability. I hereby release, acquit, & forever discharge the Facility, Collin College & their
respective employees, agents, servants, officers, directors, trustees, owners, affiliates & representatives (in their
official & individual capacities) (collectively, the “Released Parties”) from any & all liability whatsoever for any &
all damages, losses, or injuries, including death, to persons or property or both, including but not limited to any
claims, demands, actions, causes of action, damages, costs, expenses & attorneys’ fees, which arise out of, during, or
in connection with my participation in the Externship, including, but not limited to, any damages, losses, or injuries
to persons or property or both which may be sustained or suffered by me or any person in connection with my
association with, participation in, or travel to & from, & in conjunction with the Externship.
2. Indemnification. I hereby agree to indemnify, defend, & hold harmless the Released Parties from any &
all liability, loss or damages they or any of them incur or sustain as a result of any claims, demands, damages,
actions, causes of action, judgments, costs or expenses including attorneys’ fees, which result from, arise out of, or
relate to my participation in, or travel to & from, & in conjunction with, the Externship.
3. Severability. I agree that this Waiver, Release, & Indemnification Agreement is intended to be as broad &
inclusive as permitted by the laws of the State of Texas, & if any portion hereof is held invalid, it is agreed that the
balance hereof shall, notwithstanding, continue in full legal force & effect.
4. Representations. I release & discharge the Facility from all responsibility & liability for all injuries,
illnesses, medical bills, charges, or similar expenses I may incur while participating in the Externship.
5. No Employment. I understand & agree that my relationship with the Facility is not one of
employer/employee. None of the benefits provided by an employer to an employee, including but not limited to
minimum wage & overtime compensation, workers’ compensation insurance & unemployment insurance & other
employee benefits, shall be available from or through the Facility to me.
I HAVE CAREFULLY READ THIS WAIVER, RELEASE & INDEMNIFICATION AGREEMENT. I
FULLY UNDERSTAND ITS CONTENTS & SIGN IT OF MY OWN FREE WILL. I UNDERSTAND
THAT BY SIGNING THIS AGREEMENT I AM GIVING UP VALUABLE LEGAL RIGHTS.
Name (Last, First, M.I.)
Date
Address
Telephone
City, State, Zip
Signature
In case of emergency, please notify (NAME)
Relationship
Telephone
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signature
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Nurse Aide, Nursing Refresher (RN),
EKG, and Dental Assistant
Pre-Admission Application
Page 5 of 7
November, 2018 – PreAdmission Application
Clinical Rights & Expectations
1. As a student, my behavior at site is to be professional. If, after clinical hours have begun, I am asked to leave
site due to poor performance, behavior, attitude, or insubordination, Collin College is under no obligation to
find me another site. The obligation held by Collin College will have been fulfilled, & my tuition will not be
refunded.
2. I understand that I am expected to arrive at my site with all necessary paperwork (skills checklist,
timesheet, & personal identification). I will arrive at least 10 minutes prior to my interview and/or shift
start time.
3. Once my clinical hours have begun, I will take initiative with tasks & be open to instruction & new
techniques. I will be coachable in all aspects of the profession.
4. Timesheets are due every week. I will have them signed by my site supervisor & will return them to Collin
College each week.
5. After completing my assigned hours within the timeframe of my clinical, I will submit my completed &
approved skills checklist to my instructor. If I am not able to complete my hours prior to the end-date of my
course, I will need to submit a Request for Extension.
6. My site supervisor will have the opportunity to submit an evaluation upon the completion of my hours. The
evaluation may be given by the site supervisor directly to the Collin College instructor who will then review it
with me. Poor performance on this evaluation will result in a grade of No-Pass (NP).
a. If the NP is due to poor behavior & I would like an opportunity to earn a Pass-Competency (PC) for
the clinical, I will be required to enroll in Health Career Success, then repeat the clinical. Repeats of
all classes will require new registration & payment in full.
b. If the NP is due to poor performance on skills & I would like an opportunity to earn a Pass-
Competency (PC) for the clinical, I will be required to repeat the full course or a remediation course,
then repeat the clinical. Repeats of all classes will require new registration & payment in full.
I have read the above rights & expectations & will comply with the best of my ability.
Student Signature Date
Student Printed Name
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signature
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Nurse Aide, Nursing Refresher (RN),
EKG, and Dental Assistant
Pre-Admission Application
Page 6 of 7
November, 2018 – PreAdmission Application
(For Dental Assistant Students Only)
Collin College
Dental Assistant Program
Communicable Disease Statement
Student/Faculty Blood borne Exposure Agreement Form
This document is a waiver and release of liability for the Collin County Community College District (“CCCCD”),
its Board of Directors, its officers, agents, employees, and assigns.
I have been informed and am fully aware of the risks of exposure to blood and body fluids and the potential risk
for transmission of blood borne and other infectious diseases during patient care activities. I do hereby WAIVE
and RELEASE any and all liability, and agree to hold CCCCD, its Board of Directors, its officers, agents,
employees, and assigns harmless, for any and all death, bodily injury, sickness, illness, disease, contagion, mental
anguish and emotional distress, or property damage, on or off CCCCD property, or suit which I may or can have
against them on account of exposure and/or treatment to blood or bodily fluids. Understanding my risks, I agree
to treat all patients as assigned to me, regardless of the current medical state of the patient. If I refuse to treat any
patient, I realize that my academic success may be affected by my decisions.
I HAVE READ, UNDERSTOOD AND AGREE TO THE CONDITIONS AS DESCRIBED ABOVE. THIS
WAIVER AND RELEASE IS BINDING ON MY PERSONAL REPRESENTATIVES AND ASSIGNS.
I represent that I am 18 years of age or older and that I am signing this document of my own free will.
______________________________ ____________________________
Signature Date
______________________________
Print Name
______________________________ ____________________________
Witness Date
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signature
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Nurse Aide, Nursing Refresher (RN),
EKG, and Dental Assistant
Pre-Admission Application
Page 7 of 7
November, 2018 – PreAdmission Application
ArcPoint Student Background Check Instructions
All students applying for admission to specific healthcare programs must complete a student background check through
ArcPoint. The cost of this service is $45.
Typical background reports will take 2-4 business days to complete. All information is considered confidential and as
such will not be used for any purposes other than to determine an applicant’s eligibility.
ArcPoint Drug Screening Instructions
Organization/Company Collin College – Continuing Education in accordance with their policies hereby require you to go
to ArcPoint to complete drug screening. The cost of this service is approximately $30.
ArcPoint Vaccine Verification Instructions,
Go to ArcPoint Labs and submit all of your vaccine documentation. These documents should not be submitted to Collin
College. Submit copies only, documents will not be returned.
ArcPoint Labs will collect documentation on the following vaccines:
□ MMR – 2 doses (in accordance with CDC requirements) or positive titers through bloodwork
□ Varicella – 2 doses (in accordance with CDC requirements) or positive titers through bloodwork
□ Hepatitis B – 2 doses (in accordance with CDC requirements) or positive titers through bloodwork
□ Tetanus – 1 dose within the past 10 years
□ Tuberculosis – negative skin test or chest X-ray within the past 12 months
□ Flu – current year’s flu vaccine (Sep-Apr)
This documentation will be collected by ArcPoint Labs, verified, and consolidated into a standardized format. The cost of
this service is $30. Collect the vaccine printout form from ArcPoint Labs and submit to the CE Health Science office
along with your other paperwork.
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