• What semester are you applying for?*
  • Format: 000-000-0000.
  • Do you live in Nevada?*
  • Do you intend to seek employment in Nevada upon completion of your program?*
  • Do you have current medical insurance?*
  • Date of Your Background Check Submission:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Your Drug Test Submission:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Identification

  • Expiration Date of AHA BLS CPR card?*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Hepatitis B Series (3 doses) or Titer

    The hepatitis B vaccine is a series of 3 shots. You need two by the start of class.

  • Hepatitis B Vaccine Status:*
  • Dose 1 Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Dose 2 Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Dose 3 Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Titer Drawn Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • MMR Series (2 doses) or Titer

    MMR vaccine is a series of two shots.

  • MMR Vaccine Status:*
  • Dose 1 Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Dose 2 Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Titer Drawn Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Varicella Immunity, Titer, or Verified History of Chickenpox

  • Varicella Vaccine Status:*
  • Dose 1 Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Dose 2 Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Titer Drawn Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Diagnosis or Clinical History:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Tuberculosis (TB), QuantiFERON or Chest X-ray

    TB vaccine is a series of two shots. QuantiFERON must be within the last year. Chest x-ray should be within the last 5 years.

  • Tuberculosis Vaccine Status:*
  • Dose 1 Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Dose 2 Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • QuantiFERON Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Chest X-ray Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • FLU

  • Flu Vaccine Status:*
  • Flu Vaccine Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • COVID-19

  • COVID-19 Vaccine Status*
  • COVID-19 Vaccine Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Other

  • Date of Tetanus, Diphtheria, and Pertussis vaccine?*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Certification and Acknowledgment

    By pressing submit, I certify that all of the information provided above is true, correct and complete. Additionally, I understand that this program will only earn me a TMCC certificate of completion. In order to obtain my CRCST Certification, I must take the certification exam and provide my signed hours from my clinical facility to HSPA, which leads to professional licensure in Nevada. Licensing requirements vary by state and territory, and relocating may impact my eligibility for licensure. If I do not reside in Nevada and/or do not plan to seek employment there, my application will be reviewed to determine my eligibility for licensure in my state before acceptance into the program.

  • Should be Empty: