Fillable Surgical Technology Program Application Applications Available: Rolling Admissions (Anne Arundel Community College)

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Surgical Technology Program Application Applications Available: Rolling Admissions (Anne Arundel Community College)

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Surgical Technology
Program Application
Applications Available: Rolling Admissions
ADMISSION REQUIREMENTS
To become a candidate for selection to the Surgical Technology Program, please complete and return the attached
application by email to vbardhi@aacc.edu
or mail 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 surgical technology course sequence on a rolling admission basis. The program will
begin each spring term. Students will apply for the program only after meeting all academic and admission criteria.
Incomplete applications will be returned to the student and can be resubmitted once they are complete. Students will
receive an email sent to their AACC email account regarding placement if qualified. Students need only apply once to
the program, providing their application is 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:
•
First consideration will be given to candidates whose resident address is in Anne Arundel County for at least three
months prior to the date the application is submitted. The Address Verification form and supporting documentation
must be submitted with the application via email to vbardhi@aacc.edu
. Out-of-county applicants will be reviewed if
space is available.
•
Attendance at a mandatory information session. You may call 410-777-7310 for dates and times or visit
https://www.aacc.edu/apply-and-register/credit-application/health-science-applicants/.
•
During summer and fall 2020 semesters, real-time virtual information sessions will be considered face-to-face.
•
Must satisfactorily complete all academic and admission requirements.
•
Must have a minimum adjusted grade point average (GPA) of 2.0 at this college.
•
Prerequisites and chemistry requirement must be complete with a C or better by the date the application is
submitted.
•
Official transcripts, if applicable. Official transcripts are to be received by AACC 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. Transcripts
must be on file in the Records Office prior to making application or attached to the application at time of submission.
•
Final acceptance in the program shall be contingent upon satisfactory completion of a criminal background check
and health examination record and submission of a copy of the required CPR card by the stipulated
deadlines.
Upon receipt of the application, students will receive an email sent to their AACC email account regarding the status of
their application.
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 program are given conditional acceptance. Students who are granted conditional
acceptance must submit a criminal background check, health examination record and current American
Heart Association Basic Life Support (BLS) CPR certification by designated deadlines. Students who do not
meet deadlines will not be further considered for admission.
o
Waitlist: In the event there are more qualified applicants than seats available, qualified applicants not
initially selected for conditional acceptance will be placed on a list in rank order and notified for selection
when a seat becomes available. If applicant declines the seat, they will need to reapply for a future seat
in the program.
Note: Any applicant having a change of mailing address, email address, or telephone number during the application
process must notify the Admissions Office by email at vbardhi@aacc.edu.
IMPORTANT INFORMATION
1.
Direct all inquiries regarding the application process to Valerie Bardhi via email at vbardhi@aacc.edu.
2.
All Health Sciences students who are offered admission and/or clinical placement will be required to submit 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 of 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 and any and all programs to comply
with drug screening.
G:\ALHEALTH\HDrive\AHCOMMON\TDN\Applications 2020-2021 IC Approved FINAL\Word copies\SGT Application.Final. IC Approved.6-23-2020.docx
SURGICAL TECHNOLOGY
PROGRAM APPLICATION
Applications are accepted for the Surgical Technology Program on a rolling admission basis for program selection. The
program will begin each spring term. Students need only apply once to the program, providing their application is complete.
A future seat will be slotted once the applicant meets the criteria for admission.
If you have previously submitted your official transcript(s) to Records and Registration at AACC, it is your responsibility to
ensure that the transcript(s) have been posted by the time you submit your application. Transcripts are considered
official only when received by Anne Arundel Community College in the sending institution’s original sealed envelope or
through acceptable electronic method. If the official transcript(s) are not posted, the application will be considered
incomplete and will be returned.
Transcript(s) being submitted to AACC for the first time must be in the sending institution’s original sealed envelope and
attached to this application. Students are responsible for making sure official transcripts have been received by the
college if previously submitted. You will be notified by the
Records Office of any courses that do not transfer as equivalent
to coursework at AACC.
Subm
it 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 on this application will be your address of record. It is your responsibility to notify the
Health Sciences Office as well as the Records Office of name, address and phone number changes during the
application process.
Applicants are advised to check their AACC email account periodically for placement updates and
notices.
Home Phone
Cell Phone
Work Phone
AACC Email Address – Required No other email is acceptable
@mymail.aacc.edu
By signing below, I agree/understand the following:
1.
I attended a mandatory Surgical Technology information session on (date).
2.
I have an active admission status at AACC and am in Good Standing (2.0 GPA>) with the college.
3.
My AACC email address is required for correspondence with AACC.
4.
I have submitted final official transcripts* from ALL previously attended colleges. International
students must submit official transcript evaluation report from ECE, WES or SpanTran to
verify/authenticate your high school and/or college transcripts.
5.
I have submitted an official transcript* to verify graduation from either high school/GED or date college
degree conferred if appropriate.
6.
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.
7.
I understand that by filling in my name below, it will be considered my signature.
*T
ranscripts are considered official only when received by Anne Arundel Community College in the sending
institution’s original sealed envelope or by acceptable electronic submission.
SIGNATURE: Date:
PREREQUISITE REQUIREMENTS
Must be completed with a grade of C or better by time of application submission.
Due to the selection process, the Surgical Technology program cannot accept
Pass/Fail as a replacement for letter grades in the required courses.
SURGICAL TECHNOLOGY
PREREQUISITE
GRADE CREDITS
EARNED AT
COLLEGE/UNIVERSITY
TERM & YEAR
COMPLETED
BIO 231 Human Biology 1
and
BIO 232 Human Biology 2
OR
BIO 233 Anatomy and
Physiology 1
and
BIO 234 Anatomy and
Physiology 2
MDA 113 Medical Terminology
(MDA 100 is not acceptable)
CHEMISTRY
Completed a chemistry course and earned a grade of C or better.
U.S. High School Chemistry (1 credit) or CHE 011 (2 equivalent hours) or CHE 103/111 (3-4 credits)
If completed in high school, you MUST submit a final official high school transcript.
If home schooled, the high school curriculum must be under a recognized umbrella organization with the supervision of a
state-approved curriculum. AACC may require a course syllabus so that our chemistry department chair can review and
approve the curriculum.
Chemistry requirement received from: GRADE: YEAR/SEMESTER:
INTERNATIONAL STUDENTS
Have you submitted an official transcript evaluation report from ECE, WES, or SpanTran to verify/authenticate your high
school and/or college transcripts to the Records office prior to or with your program application?
Yes No
AGENCY USED:
GENERAL EDUCATION REQUIREMENTS
All general education courses listed below must be completed with a C or better
prior to graduation from the Surgical Technology Program. Due to the selection
process, the Surgical Technology program cannot accept Pass/Fail as a
replacement for letter grades in the required courses.
*Courses must be completed by the end of the first year/term one of the program
COURSE
(Grades must be C or better)
GRADE
CREDITS
COLLEGE WHERE TAKEN
SEMESTER/YR COMPLETED
or
CURRENTLY ENROLLED
*General Microbiology BIO 223
(corequisite with SGT 100)
*General Education Math (From Catalog)
*ENG 101/ENG 101A
Previously completed ENG 111, 115 or 121
will be accepted
.
*CTA 100 or CTP 103
Previously CSI 112, CSI 113 & CTA 103
will
be accepted.
PSY 111
Arts & Humanities Course
Students enrolled in the Surgical Technology program must complete an Arts & Humanities course that satisfies the diversity
requirement to qualify for graduation. If you have previously completed an Arts & Humanities (General Education Requirement
)
and/or diversity course you should consult with an academic advisor to make sure that you have met both requirements.
COURSE:
GRADE: _____________
CREDITS: ____________
INSTITUTION WHERE COMPLETED: __________________________________
SEMESTER/YEAR:
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
No
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.
Yes
No
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.
Yes
No
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.
Yes
No
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.
Yes
No
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.
Yes
No
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.
NOTE: 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.
I certify that the information on this application is true and accurate to the best of my knowledge. Falsification or
misrepresentation of any information on this application may result in being denied admission, or if enrolled, dismissed from
this program. I understand that final acceptance into the Surgical Technology Program shall be contingent upon satisfactory
completion of a criminal background check and satisfactory completion of a health examination record.
I understand that by filling in my name below, it will be considered my signature.
Signature: Date:
Print Name:
Notice of Nondiscrimination: 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.
Please review prior to submitting this application. This application must be completed in its entirety.
The Address Verification Form is part of the application packet and must be completed in its entirety and submitted
with the application. Be certain to include two (2) forms of supporting documentation as stipulated on the form.
Questions pertaining to this form should be addressed to Melissa Mumma in the Records Office at 410-777-2721 or
mamumma@aacc.edu
.
Out-of-county applicants will be reviewed only if space is available.
June 2020
Notice of Nondiscrimination: 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.
ADDRESS VERIFICATION
101 College Parkway, Arnold, Maryland 21012-1895 410-777-2243
ADDRESS VERIFICATION FOR HEALTH SCIENCE PROGRAM APPLICANTS
Directions: This form must be completed entirely and supporting documents submitted as part of the health sciences
program application process. Applications submitted without this document will be returned as incomplete.
If you the student support yourself, provide a minimum of two of the documents listed below in your name, at current
resident address that are dated three months prior to the application deadline date.
OR
If for the most recent 12 months, you, the student, have resided in Anne Arundel County, but are supported by someone in
another Maryland county or state, provide a minimum of two of the documents listed below in your name, at current resident
address that are dated three months prior to the application deadline date.
OR
If for the most recent 12 months, another person(s) has provided one-half or more of your financial support, provide a
minimum of two documents listed below in your supporter’s name, showing current resident addresses that are dated three
months prior to the application deadline date.
In addition, you will need to provide one document from the list below in your name showing current resident address and
dated three months prior to the application deadline date in addition to the two documents from your supporter. The
supporter must also complete the information requested in Section B.
Military Personnel Only:
Complete this form with a copy of your military ID (also dependent ID, if spouse or dependent), copy of orders, and a copy
of housing assignment, lease, deed or utility bill showing your resident address.
Example: All documents must be dated three months prior to application submission date.
Acceptable Documents
• Maryland Driver’s License
• Voter Registration Card
• Copy of Deed of Trust or Signed Lease
• Maryland Withholding Form – MW 507 (Not U.S. W-2)
• Maryland Income Tax Return (not U.S.)
• Utility Bill including gas, electric, water, phone, cable, etc.
• Vehicle Registration Card
The college reserves the right to request additional information and documentation as necessary.
SECTION A – TO BE COMPLETED BY STUDENT
Student Name
Student ID or SSN (last 4 digits)
Resident Address
City
State
Zip
County
Day Phone
Evening
Dates of Occupancy at above address
Own
Rent
Previous Address
City
State
Zip
How long did you live at this previous address?
Are you registered to vote?
Yes
No
County
State
Do you possess a valid driver’s license?
Yes
No
If yes, what state issued?
County
Date of Issuance
OFFICE USE ONLY
Program and Term:
Surgical Technician - FA20
Do you own a motor vehicle? Yes No
If yes, in what state issued? County Date of Issuance
Do you have the use of another person’s motor vehicle? Yes No
If yes, provide name Relationship to student
Are you paying Maryland income tax for this year on all earned income? Yes No
If yes, what county?
List where you have filed tax returns for the past two (2) years:
Year State County
Year Sta
te County
If employed, is Maryland income tax currently being withheld? Yes No
If yes, what county?
For the most recent 12 months, has another person(s) provided one-half or more of your financial support?
*Yes No
*If the answer to the above question is “Yes”, SECTION B of this form must be completed by your supporter.
Additional Information
The college reserves the right to request additional information and documentation as necessary.
I CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS CORRECT TO THE BEST OF MY KNOWLEDGE.
Signature of Student (required) Date
OFFICE USE ONLY
ACCEPTABLE DOCUMENTS: MILITARY/BRAC WAIVER:
____ MD driver’s license ____ Military ID (& Dependent ID if spouse or dependent)
____ MD income tax return (not U.S.) ____ Copy of Orders
____ Voter Registration Card ____ Copy of housing assignment, lease, deed or utility bill
____ Vehicle registration showing resident address
____ Utility bill showing home address
____ Copy of deed of trust or signed lease
____ MD withholding form – MW 507 (not U.S. W-2)
STATUS OF RESIDENT ADDRESS
Anne Arundel County Other MD county Out-of-State Term & Year
Authorized signature: Date:
SECTION B
TO BE COMPLETED BY SUPPORTER IF YOU ANSWERED “YES” to the following questio
n:
For the most recent 12 months, has another person(s) provided one-half or more of your financial support?
Name of supporter Relationship to student
Supporters Address
City State Zip
County Day Phone Evening
Date of Occupancy at above address
Own
Rent
Previous Address
City State Zip
How long did you live at this previous address?
Are you registered to vote? Yes No County
Do you possess a valid driver’s license? Yes No
If yes, in what state issued? County Date of Issuance
Do you own a motor vehicle? Yes No
If yes, in what state issued? County Date of Issuance
Do you have the use of another person’s motor vehicle? Yes No
If yes, provide name Relationship to student
Are you paying Maryland Income tax for this year on all earned income? Yes No
If yes, which county?
List where you have filed tax returns for the past two (2) years:
Year State County
Year S
tate County
If employed, is Maryland income tax currently being withheld? Yes No
If yes, in which county?
Additional information:
The college reserves the right to request additional information and documentation as necessary.
Signature of supporter: Date:
Notice of Nondiscrimination:
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\Admissions Forms\Residence Petitions by Program\Residence Petition Template 5.22.2020
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Surgical Technology Program Application Applications Available: Rolling Admissions (Anne Arundel Community College)

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Completed 22 July 2020

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