MAA pplication by fxz3722

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									                                                                                                              Please check the box
                                                                                                              if Veteran
                                                                                                               Veteran




                                               Medical Assisting Application
                                               Semester_____ Year_______



Name _____________________________________________________________________________
         Legal Last Name             First         Middle                          Social Security Number


Mailing Address______________________________________________________________________
                           Number and Street                City           State                   Zip Code

Home Phone _______________ Message Phone _______________                   Birth Date _______________

WHC Email address_______________________________ Other Email Address_________________

CA Resident _____ years         CA. Drivers License______________ Photo ID # ______________
Birth Certificate if no DL________

Did you graduate from high school or do you have a GED? ________________________

Are you currently enrolled in college? _______ Where? ________________________

Have you previously attended West Hills College? ______            Year(s) Attended ___________


The final responsibility for the completeness and accuracy of this application packet rests with the applicant.

I hereby affirm under penalty of dismissal that all information supplied in this application is complete and accurate.

_________________________________________                                  ___________________
Applicant Signature                                                        Date
West Hills Community College District
Health Career Programs


RELEASE OF INFORMATION

Personally identifiable information from educational records may not be released without the prior written consent of the
student, except as specified under the provisions of FERPA (Family Educational Rights and Privacy Act of 1974).

The West Hills Community College District Health Careers Programs are required by their contracts with various health
facilities for clinical placements with the clinical and community institutions to provide certain personal information to
the agency. The release of information is required in order to allow you to receive your clinical experience. The clinical
agencies are required to have certain information because of JACHO accreditation and other Federal requirements.

□       I am a Contract Ed student, if this box is checked, you are a Contract Ed student. We are required by our
        agreement with the sponsoring hospitals to share information with them regarding your application, attendance
        and academic and clinical progress. You have already agreed to this information reporting in exchange for being
        sponsored in the Contract Ed Program.

It is therefore necessary for you to provide your clinical instructor a Release of Information form when you give him/her
the immunizations, TB test results, malpractice insurance information, background clearance, physical exams, etc. as
requested by each clinical agency.

By signing this form you are giving the District and the Health Careers Programs or its representative such as your clinical
instructor, the right to provide your personal and academic information to the agency in need of specific information
necessary for your clinical rotation or Contract Ed Program or for your Extern position. This includes the release of your
grades on a pass/fail basis and for any safety issues that might arise.

Name of Student:       _______________________________________________
Please print your name

Signature of Student:   __________________________________________
Please sign legibly

Date:   _______________

Student ID Number: ____________________________
I _______________________certify that I have no criminal offenses on my personal record. I
       print name

understand that if the background check report reveals past activities that make me ineligible, I

will be terminated from the WHCL Medical Assisting Program.




____________________________________                      ____________________________
          Student Signature                                         Date
              Cost for Medical Assisting Training Program-Estimates

Fees:

The student is responsible for the cost of all needed supplies and materials for this program.
         The following is the estimated cost of all supplies that are required for each student.

Item                                                                                           Estimated
                                                                                                 Cost
Background Clearance & Drug Screen                                                                 $75-$85
Tuition @ $26/unit - 9. units                                                                      $234.00
CWEE Co-Requisite class – 4 units                                                                  $104.00
Physical & TB Test (prior to admission) (Cost may vary)                                            $160.00
M.A. Textbook, Study Guide w/CD                                                                    $116.01
Classroom supplies                                                                                  $30.00
Watch with second hand (price and style may vary)                                                   $30.00
Uniforms (2 sets) Blue top – White Pants (price and style may vary)                                 $90.00
White nurse shoes (see dress code) (price and style may vary)                                       $75.00
CPR card (WHC offers class while in the program or may complete elsewhere as                        $65.00
long as its American Heart Association approved).
Stethoscope (price and style may vary)                                                              $60.00
Copy of Immunization record showing (cost may vary)
          Rubeola                                                                                   $50.00
          Varicella                                                                                 $50.00
          Hep B Series: Hep B 1, 2, 3                                                              $150.00

Approximate Total Cost:                                                                            $1300
All costs are approximate and may be more or less than the amount shown above.
West Hills College Lemoore does not sponsor students to sit for the state test. Any and all
fees for the Department of Health Services and American Red Cross/American Heart
Association written and skills exam are the responsibility of the student.
You can also contact your local One Stop office for possible additional assistance.
Workforce- 935-7880 (Fresno County) or JTO- 585-3532 (Kings County)
Veterans’ Employment-Related Assistance Program – 312-7060
                                                        Health Examination Form


Dear Doctor:
The individual listed below is applying for the Medical Assisting Program. As per California regulations, a physical must be
completed prior to entering the program. Please fill out the following form regarding physical health and identify any possible
limitations.

Student’s Name __________________________________________                         Date ___________________
Have you had any of the following complaints?
Yes      No                 Yes     No                         Yes      No                   Yes    No
□        □ Headaches        □       □ Blackouts                □        □ Joint pain         □      □ Hay fever/asthma
□        □ Dizziness        □       □ Unconsciousness          □        □ Chronic fatigue    □      □ Shortness of breath
□        □ Frequent colds   □       □ Diarrhea                 □        □ Chest pain         □      □ Difficult urination
□        □ Hoarseness       □       □ Nausea/Vomiting          □        □ Palpitations       □      □ Nighttime urination
□        □ Tarry Stools     □       □ Enlarged glands          □        □ Excessive thirst   □      □ Sleeplessness
□        □ Indigestion      □       □ Excessive gas            □        □ Ankle swelling     □      □ Anxiety attacks
□        □ Constipation     □       □ Blood in Stools          □        □ Night sweats       □      □ Yellow jaundice
□        □ Cold feet  If you answered yes to any of the above conditions, please explain:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_______________________________________________________________
How many pillows do you use? ______ What major operations have you had? ________________
_______________________________________________________________________________________________________
I grant permission to the below signed physician or representative to release this information to West Hills College:
______________________________________________________
Signature Student                                     Date

                                                          Physical Assessment
EENT ___________________________                        Urinary __________________________
Cardiovascular____________________                      Muscular ________________________
Respiratory ______________________                      Skeletal _________________________
GI _____________________________                        Neuro __________________________
Allergies ________________________                      Medications ______________________



Date of TB skin test _________ Results/Date ________ Read by _____________

Physical Requirements - Please check the following tasks the individual is able to perform:
Lift, push or pull objects weighing 50 lbs □       Stand and walk without difficulty        □
Stand for long periods of time             □       Bend at the waist without difficulty     □
Perform basic range of motion              □       Limitations, if any ___________________________________
_____________________________________________________________________________________________



Signature Physician                                                     Date
                             West Hills Community College Lemoore
                                Hepatitis B Vaccine Declination

I understand that due to exposure to blood or other potentially infectious materials I may be at risk of
acquiring Hepatitis B Virus (HBV) infection.

I have been informed by West Hills Community College the importance to receive the Hepatitis
vaccination series. However, I decline the Hepatitis B vaccine at this time. I understand that by
declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease.

I understand that by declining this vaccine, I may be limited in the facilities in which I may complete
my clinicals, and the duties I may perform during my clinical skills. The inability to complete my
clinical objective will result in the failure to pass the course.

This is a formal notification that you have been notified of the importance and decline Hepatitis B
vaccination at this time.



______________________________________                       __________________________________
Student Name                                                 Date



______________________________________
Signature

______________________________________                       __________________________________
Witness                                                      Date

								
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