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): 										

Social Security Number: 				   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:

Name							   SS#					

All programs are committed to the College's equal access/equal opportunity plan in student admission criteria.

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#					

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#					

EXPERIENCE/OBSERVATION:  (NOT MANDATORY FOR APPLICATION SUBMISSSION)

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

												

												

Name							   SS#					

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					

Name							   SS#					

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#					

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.

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: