Surgical Technology Program Application

Date of Application *

Month Day Year

Year of desired program admission *

Admission to South Arkansas Community College Surgical Technology Program is based on completing the established criteria for the program. Applications may be accessed and submitted at any time through the SouthArk website.

Instructions for completion of application packet:

Please follow all directions carefully.

Use the transcript release form that is provided on the SouthArk website to request all official transcripts from any high school, colleges and universities, technical or trade schools previously attended.

Three recommendations are required for acceptance. Ask your recommender to complete the provided form and return it to the Surgical Technology Program Director by mail, or the student may bring the form back in a sealed envelope with the recommendation originator’s signature across the back flap.

All applicants will schedule to interview either by phone or in person with the Program Director or program faculty.

If you need additional information, please contact Mr. Vincent Dawson at 870.875.7207, ext. 207.

A background check is required for admittance into ALL SouthArk Health Science programs. DO NOT complete a background check until instructed to do so by your Program Director.

Medical History Requirements:

Please Note: Upon acceptance into the Surgical Technology Program, students are required to provide:

1. Proof of PPD skin test or evidence of a negative chest x-ray if skin testing is positive or not allowed (prior to first day)

2. Proof of Hepatitis B immunization (prior to first day)

3. Proof of immunity to varicella or a signed declination statement. Proof may consist of 1) proof of vaccination, 2) statement of physician verifying that student had varicella, or 3) varicella antibody titer indicating immunity. (prior to first day)

4. Influenza virus vaccine (can be taken prior to first day but will need by October)

5. Current American Heart Association CPR certification (can be taken prior to first day but will can be taken with class in the fall semester)

6. Physical examination (prior to first day)

7. Drug screen (fall semester, scheduled in program)

Applicant's Full Name *

First Name Middle Name Last Name Birth Name

Name you prefer to be called

Date of Birth *

Month Day Year

Social Security Number *

Student ID *

Home Email Address

School Email Address

Home Phone Number *

Area Code Phone Number

Cell Phone Number

Area Code Phone Number

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Emergency Contact *

Emergency Contact Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Emergency Contact Phone Number *

Area Code Phone Number

Place of Employment

Work Phone Number

Area Code Phone Number

Family Physician

Physician Phone Number

Area Code Phone Number

The following information is optional and used for statistical and affirmative action purposes. It does not affect eligibility for admission.

Sex

Male Female

Predominant Ethnic Background

American Indian/Alaskan Native Asian or Pacific Islander White/Non-Hispanic Black/Non-Hispanic Prefer not to respond

Surgical Technology

Admission Application

Educational History

Employment

Background

Personal Statement

Confidentiality Agreement