______________________________________ ____________________
Starting January, 2021
Name: __________________________________________________________
Student ID Number: _______________________________________________
Address: ________________________________________________________
City: _____________________________ State: ______ Zip: _____________
Phone Number: __________________________________________________
Second Phone Number: ____________________________________________
SCC Email Address: ________________________________________________
Along with this application, I am submitting my letter of intent.
DO NOT INCLUDE: copies of immunization records, CPR cards, reference letters, etc.
I am applying for admission to the Respiratory Therapist program. I understand that the
program is competitive and I must first be accepted. I have completed or am in the
process of completing the required prerequisite courses at this time.
Applicant’s Signature Date
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Somerset Community College
Respiratory Therapist Program
Memorandum of Understanding
This Memorandum of Understanding must be signed, dated, and submitted at the time
of application to the program. Please initial each item.
______ I have read and understand the information in the online Respiratory Therapy
pre-admission conference presentation. Questions can be directed to the Respiratory
Therapy coordinator at 606.878.4745 or angie.mills@kctcs.edu
______ I understand that clinical facilities require a criminal background check and a
drug screen before being allowed to participate in clinical experiences. I also
understand that the Respiratory Therapy program requires me to have a criminal
background check and a drug screen once a year before participation in clinical
experiences. If I do not “pass” the test, the facility may refuse to allow me to practice in
their facility and may be dismissed from the program. The cost of these checks/screens
will be my responsibility.
______ I understand the Respiratory Therapy program classes and clinical schedules are
non-negotiable and will vary each semester.
______ I understand that if admitted to the program, I must submit proof of certain
immunizations, documentation of yearly TB skin tests, and maintain CPR certification.
Students must begin the series of Hepatitis B vaccinations or sign a Hepatitis B
declination form before beginning clinical. I must also purchase liability insurance, as
provided through KCTCS, at the beginning of each semester. I may also be required to
complete an orientation to each clinical facility.
______ I understand that there are mandatory purchases for the program including, but
not limited to, textbooks, uniforms, shoes, etc.
______ I understand that it is my responsibility to submit all required application
materials by the appropriate deadline date.
Student Signature
Student ID Number
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