Associate Degree Surgical Technology Program
Name_________________________________________________ Student ID #________________________________
Mailing address ___________________________________________________________________________________
City _______________________________State _______________ Zip ____________County_____________________
Phone (home) _______________________________________ (other phone #) _________________________________
Student e-mail ____________________________________________________
--Check all that apply:
I am a current high school student (or just graduated this year) I am a current SCC student
I am a current student at another college I am not currently enrolled in college
List every college, university, and technical college attended ____________________________________________________________________
Have you taken the ACT exam? ______YES_______NO (NOTE: ACT score in PeopleSoft are required for application)
What is your highest composite ACT score? _______________________________________________
Have you ever been convicted of or have charges pending against you for a felony or misdemeanor in any state jurisdiction? No ______ Yes ______
(If yes, please explain fully)
Do you understand the nature of the field of Surgical Technology? Yes _______ No ________
Priority for admission may be given to students who complete their general education classes before applying to the program.
Courses in this box must be completed before program admission
(BIO 137) Human Anatomy & Physiology I
(BIO 139) Human Anatomy & Physiology II
(BIO 118) or (BIO 225) or (BIO 226) or (BIO 227) Microbiology
(AHS 115) or (CLA 131) or (MIT 103) Medical Terminology
MAT 110 or higher
All courses except one in this box must be completed prior to program admission
ENG 101 or ENG 102 or ENG 105 Writing
Digital Literacy
Social/Behavioral Science
Signature of student ______________________________________________________ Date __________________
click to sign
click to edit