Surgical First Assistant Program - Gulf Coast Community College

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GULF COAST STATE COLLEGE HEALTH SCIENCES DIVISION 5230 West U.S. Highway 98 Panama City, FL 32401-1058 (850) 913-3311 (850) 747-3246 - fax 1-800-311-3685 ext. 3551 or 3311 APPLICATION FOR ADMISSION SURGICAL FIRST ASSISTANT PROGRAM CCC - College Credit Certificate A.S. - Associate of Science (add'l. Gen Ed courses required) Check if you are a CST Answer all questions; please TYPE or PRINT (please use black ink). Name ____________________________________________________________________________________________ First Middle Last Maiden Name Male Female E-mail __________________________________________________________________ Home Address ______________________________________________________________________________________ Street and No. City State County Zip Permanent Mailing Address (if different from above) ___________________________________________________________ Social Security #__________________GCSC Student ID #_______________ Phone: (_____) ____________________ Business Phone: Area Code: (_____) _______________________ Permanent Phone#: (_____) _____________________ Phone number where a message can be left at any time. EDUCATION Official Transcript(s) must be received by the Office of Admissions and Records. All schools and colleges attended must be listed for the application to be complete. Name of School High School or GED: Location of School From Month/ Year To Month/ Year Did you Receive Diploma? Degree? Certificate? What was your Major/Minor? College or University: College or University: Type Issued by which State / Agency License No. Expiration Date Professional Licenses ___________________ _______________________ ___________________ ______________ or Certifications ___________________ _______________________ ___________________ ______________ For CST applicants, please attach a copy of your certification verification from AST website, or a copy of your card showing that you are currently certified.
CONTACT INFORMATION FOR EMERGENCIES AND FOLLOW UP Please provide information about two people who will always know where to locate you. Name 1. ____________________________ 2. ____________________________ Mailing Address _______________________________ _______________________________ Telephone Number _________________________ _________________________ WORK EXPERIENCE AND / OR VOLUNTEER EXPERIENCE LAST 3 YEARS EMPLOYER:______________________________________________________________________________________ Address _________________________________________________ Telephone No. _________________ Ext._______ Street and No. City State Supervisor’s Name ________________________________________ Title ____________________________________ Dates employed: From __________ To ____________ Nature of Your Job Duties ______________________________ Mo./Yr. Mo./Yr. Reason for Leaving _____________________________________________Full-Time _________ Part-Time _________ _________________________________________________________________________________________________ EMPLOYER:______________________________________________________________________________________ Address _________________________________________________ Telephone No. _________________ Ext._______ Street and No. City State Supervisor’s Name ________________________________________ Title ____________________________________ Dates employed: From __________ To ____________ Nature of Your Job Duties ______________________________ Mo./Yr. Mo./Yr. Reason for Leaving _____________________________________________Full-Time _________ Part-Time _________ PLEASE READ AND SIGN THE FOLLOWING I hereby certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or falsification of information is cause for denial of admission from the College. I understand that illegal use, possession, and/or misuse of drugs are reasons for immediate dismissal from any of the programs in the Health Sciences Division. I understand that background checks and drug screening tests are routinely used at most healthcare facilities for employment purposes. I understand that fingerprinting and criminal background checks are a requirement for enrollment due to requirement at the clinical agencies. It is possible to graduate from a program and obtain certification, but be denied some employment options due to an unfavorable current background check or drug screen. In compliance with clinical requirements, I understand that I may be subject to drug screening. The school does not guarantee employment at any facility. I understand that I must meet all requirements for graduation. We offer this information contained in this statement and the application packet so that you can make an informed decision concerning making application to our program. Signature of Applicant ______________________________ Date ______________________________ RETURN APPLICATION TO: Gulf Coast State College Attn. Surgical Services Health Sciences Division 5230 W. U.S. Highway 98 Panama City, FL 32401-1058 IN CASE OF EMERGENCY NOTIFY: Name _____________________________________________ Address ___________________________________________ __________________________________________________ City State Zip Phone (______) _____________________________________
Page 1 and 2: Health Sciences Surgical Services S
Page 3: ____ Step 7. Submit Surgical First
Page 7 and 8: Surgical First Assistant Duties Ack
Page 9 and 10: MASTER SCHEDULE - YEAR 2 Recommende
Page 11 and 12: CURRENT FEE SCHEDULE ** Surgical Fi
Page 13 and 14: CURRENT FEE SCHEDULE ** Surgical Fi
Page 15 and 16: STUDENT TIME COMMITMENT This course
Page 17 and 18: Financial Aid Information Step One
Page 19 and 20: CRIMINAL BACKGROUND CHECKS Gulf Coa
Page 21 and 22: TRANSCRIPT REQUEST FORM FOR HIGH SC
Page 23: GCSC Health Sciences Division Perso

Surgical First Assistant Program - Gulf Coast Community College

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