APPLICATION FOR ACCEPTANCE
ALLIED HEALTH PROGRAMS

The program to which you are seeking admission:
Respiratory Care    

STUDENT INFORMATION:

Name: 												
		Last				First				Middle

Former Name(s): 										

SS# or Student ID: 				                  D.O.B_______________________

Mailing Address:										

		City				State			Zip

Phone Numbers:  Home (     )				 	Work (     )			
		     E-mail:______________________	Cell    (     )			

Have you previously been enrolled in an Allied Health program at Polk State College or any other community college that prepares graduates to sit for Licensure or Certification?

	_______ Yes, at PSC		_______ Yes, at another school	_______ No

If yes, please explain:

______ Yes	_______ No	Do you hold any health professional licenses or certificates?
If yes, indicate type and licensure or certificate number:

All Polk State programs are committed to the Polk State College's commitment to equal opportunity/equity/access for its programs, services and activities.

Name____________________________________ SS# or Student ID			

If you are currently employed or have recently been employed (within 5 years) by a health care facility/provider, please provide the following information:

Employer:					 	Supervisor:				

Address:											
				Mailing
								Phone (     )			
		City		State		Zip

Employer:					 	Supervisor:				

Address:											
				Mailing
								Phone (     )			
		City		State		Zip

Other employment: Provide for other employment in past five years:

Employer:					 	Supervisor:				

Address:											
				Mailing
								Phone (     )			
		City		State		Zip

Employer:					 	Supervisor:				

Address:											
				Mailing
								Phone (     )			
		City		State		Zip

Employer:					 	Supervisor:				

Address:											
				Mailing
								Phone (     )			
		City		State		Zip

Name						 SS# or Student ID				

LICENSURE INQUIRY/INFORMATION:  

Florida regulations provide that the denial of a license/certificate may occur if an individual is habitually intemperate, addicted to, or is found to be in illegal possession or involved in the sale of distribution of habit forming drugs, and/or is unfit or incompetent by reason of gross negligence, physical or mental condition or other like causes which could result in behavior that interferes in his/her practice as a health professional.

An application for licensure/certification in the State of Florida includes the following questions: A "yes" answer to any question could result in the denial of a license by the State.  If your answer to any of the questions is "YES", you must meet with the Program Manager/Director of the program prior to the submittal of the application to the program.

_____ Yes	_____ No	Have you ever been convicted or have you entered a no contest or 
guilty plea-regardless of adjudication-offense other than a minor 
traffic violation?

_____ Yes	_____ No	Have you ever been denied or is there now any proceeding to deny 
your application for a license to practice a health profession in 
Florida or any other jurisdiction?

_____ Yes	_____ No	Have you ever had a disciplinary action taken against your license 
to practice a health profession by the licensing authority in Florida 
or any other jurisdiction?

_____ Yes	_____ No	Have you ever surrendered a license to practice in a health 
profession in Florida or any other jurisdiction while any such 
disciplinary charges were pending against you?

I certify that I have read and understand the standards indicated above regarding licensure/certification as a health professional in the State of Florida.

Applicant's Signature						Date

TO BE COMPLETED (IF NECESSARY) BY PROGRAM MANAGER/DIRECTOR

I have informed the above-identified applicant regarding the licensing/certification process in the State of Florida in relation to previous criminal convictions.

Program Manager/Director				Date

Name						  SS# or Student ID___________________

EXPERIENCE/OBSERVATION:

Summarize your experience/exposure/observation in Respiratory Care.  If none, please state none.

												

												

Name						 SS# or Student ID			

THIS CERTIFICATION IS TO BE COMPLETED BY ALL APPLICANTS

I hereby certify that the facts set forth in this application are true and complete to the best of my knowledge.  I understand that discovery of any falsification of this information will result in denial of admission or prompt dismissal from the program.  Polk State College is hereby authorized during the selection process and/or during my tenure as a student, if admitted, to make any investigation that is deemed necessary concerning the above information with regard to my suitability to practice as a health professional.

							 					
Applicant's Printed Name					Date

							
Applicant's Signature					

REQUIREMENTS FOR THE RESPIRATORY CARE PROFESSION
In addition to the immunization requirements, potential applicants should be aware that Respiratory Care is a physically, mentally, and emotionally demanding profession. In order to be admitted and retained in the program, all applicants and students must be able to demonstrate the ability to independently perform the following essential cognitive, affective, and psychomotor functions. These functions are:
☤	Sufficient visual acuity, such as is needed in the accurate preparation and administration of medications, and for the observations necessary for safe patient assessment and care.
☤	Sufficient auditory perception to receive verbal communication from patients and members of the health team, including occurrences where face masks are worn by personnel (which precludes lip reading), and to assess health needs of people through the use of devices such as cardiac monitors, stethoscopes, mechanical ventilators, fire alarms, and other equipment with alarms or auditory signals.
☤	Sufficient gross and fine motor coordination to respond promptly; and to implement the skills required in meeting health needs including the manipulation of equipment and supplies.
☤	Sufficient communication skills in speech, reading, and writing in the English language to interact effectively and safely with individuals, and to communicate patient needs promptly as may be necessary in rendering patient care.
☤	Sufficient tactile ability to conduct physical assessments, to distinguish significant temperature differences, and to determine the safe use of objects in a person’s environment.
☤	Sufficient physical abilities to quickly move from room-to-room, to maneuver in small spaces and in spaces containing numerous pieces of patient care equipment, and to administer cardiopulmonary resuscitation and other life-saving skills in typical patient care situations.
☤	Sufficient interpersonal abilities to interact therapeutically and professionally with individuals, families, and groups from a variety of social, cultural, and intellectual backgrounds, as well as with individuals with emotional or psychological illnesses.
☤	Sufficient coping and communication skills to handle stressful situations in a calm and professional manner.
☤	Sufficient intellectual and critical thinking skills to make safe and rapid clinical decisions; identify cause-and-effect relationships, and to develop safe and effective patient care plans.
☤	Sufficient stamina to provide patient care and related responsibilities for extended periods of time (8-12 hours or more).
☤	Sufficient ability to quickly and safely implement written or verbal patient care plans.
☤	Sufficient ability to effectively handle multiple priorities in a stressful situation.

Name___________________________________ SS# or Student ID			

Admission into the Respiratory Care Program is contingent upon compliance with the specific requirements listed below.

1. Applicants must achieve the state standards for placement at the college level on the College Placement Test (CPT) or from recent scores on the SAT and/or ACT tests.  Reading score exempting enrollment in college prep reading courses or satisfactory completion of these courses is, also, required. 

2. Applicants must be accepted to Polk State College as a credit student with all required admission documents received by the Registrar.

3.  The following pre-requisite courses must be completed with a “C” or better prior to beginning the professional core courses (courses beginning with the prefix, RET):

	ENC 1101	English Composition I
	BSC  1085C	Human Anatomy and Physiology I
	MAC 1105	College Algebra (or higher)

4.  The application packet for the Respiratory Care Program must be submitted by May 1st in order to be considered for that Fall Semester class.  The Respiratory Care Program is offered in a two year curriculum with a new class starting in the Fall Semester.

Name						  SS# or Student ID_________________

APPLICATION CHECKLIST

The following are minimum requirements or necessary steps for consideration for admission to your selected program.  Complete each step/requirement and certify by initialing on this form that the step/requirement is met.  An academic advisor must also review your application packet, certify that it is complete, and attach the appropriate Computer Assisted Advising document.  Please, submit this form with your completed application to Registrar’s Office by the deadline.

		 	Admission as a credit student to Polk State College.

High School transcripts or GED are on file with the Registrar (scores required for out of state GED).  Not required if student has earned 12 or more academic college credit hours with a grade of "C" or better.

		 	College transcripts are on file with the Registrar.  (Transcripts 
required at time of application). (Student Services confirmation)

		 	Overall cumulative credit grade point averages (GPA) are 2.0 or
 higher. (GPA or 2.0 or higher must be maintained).

		 	Prerequisite course requirements (see previous page).

		 	Assignment completed.

_____________	Requirements for the Respiratory Care Profession has been read.

I have completed all of the above requirements.

Student's signature:                                                                                        Date:                     

PROGRAM DIRECTOR: I have reviewed this application and verified as completed.

Program Director’s Signature:						Date: