First Step Nursing Program Application



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|Documents Required for Application Submission: |Please Check/Initial Verifying Each Document Is Included: |

|Program Application | |

|2 Letter of Recommendation Forms (included at the end of this application | |

|packet) | |

|Cover Letter *See specifications below | |

Limit one program area application per student. Application deadline is Friday, March 8th. In order to be considered a candidate for interview, you must submit all the required documents listed above. All applications and documents must be submitted together as a packet in a Manilla envelope or enclosed folder. Please submit your envelopes/folders to a guidance counselor at your home school. Tentative interview dates are Tuesday and Wednesday, March 19-20 for MNHHS, and Tuesday and Wednesday March 26-27 for HCCHS. If you are a candidate for interview, you will be contacted to schedule a date and time.

Cover Letters:

This letter will be used in consideration with your interview.

Address your letter to—“To Whom It May Concern:”.

In a one page document, please answer the following questions:

• Why are you most interested in this program?

• Why should you be considered as a candidate for this program?

• What are your long term goals?

• How do you plan to utilize your future success upon completion of this program?

• Add any additional information you would like to your letter.

Information about the Pharmacy Technician Program: As a student of the Pharmacy Tech Program, you will intern at one of the following locations: Bluegrass Pharmacy or Hometown Pharmacy. In addition to on-the-job training at your intern site, this program implements a nationally certified online program called PassAssured. This online program will further provide the necessary education you will need to pass your national certification exam. You may visit for more details. Pharmacy technicians work under the direct supervision of a licensed pharmacist and perform many pharmacy-related functions. Techs may possibly fill medication orders, maintain the inventory, compound medicines, or stock machines. Pharmacy technicians are generally the face of the pharmacy, because they provide customer service to patients and relay patient needs to the pharmacists. Pharmacy techs may potentially work in community pharmacies, hospitals, or other health care organizations. Pharmacy technicians may further their education and become a licensed pharmacist.

If you are accepted into the Pharmacy Technician Program, these are the program costs: Bundled price for PassAssured Pharmacy Technician Program which includes study materials, practice tests, and the national certification exam:$399. You must provide your own transportation to your intern location.

For questions about the program please contact:

Ava Lomache, RN, BSH, Pharmacy Technician Program Coordinator

Hopkins County Career and Technology Center

1775 Patriot Dr.

Madisonville, KY

270-825-8998 or ava.lomache@hopkins.kyschools.us

PHARMACY TECHNICIAN PROGRAM APPLICATION

(Please print or type) Please Note: Complete all sections of this application. If you do not have any information to enter in a section, please write N/A.

|Name and Address |

|Name (First, MI, Last): |

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|Address: |

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|City: |State: |Zip Code: |

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|Home Phone: |Cell Phone: |

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|E-mail Address: |May we use e-mail to contact you? |

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| |Yes θ No θ |

|Additional Information |

|Parent / Guardian Name: |Phone: |

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|Parent / Guardian Name: |Phone: |

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|Name of High School Attending: |Cumulative G.P.A.: |

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|If you have taken one of the classes below, please place a check beside the corresponding course. If you are scheduled to take it, please write the Trimester and|

|year. |

|_____Medical Terminology _____Principles of Health Science A and B _____Anatomy A |

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|_____Emergency Procedures _____Allied Health Core Skills _____Anatomy B |

|_____Body Systems A _____Body Systems B _____Medical Math |

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|If you have already completed a Health Sciences/Allied Health Program, please specify the program title and date |

|completed:__________________________________________________________________________ |

|Please list any extra-curricular activities you have participated in—these activities may be sports, clubs, volunteer work, church youth groups, etc. : |

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|Work (employment)/ Community Service History |

|Job Title: |Date From: |Date To: |Hrs/Week: |Employer: |

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|Address: |Phone: |

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|Supervisor: |May we contact this employer? |

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|Reason for leaving? |Job Responsibilities: |

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|Job Title: |Date From: |Date To: |Hrs/Week: |Employer: |

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|Address: |Phone: |

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|Supervisor: |May we contact this employer? |

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|Reason for leaving? |Job Responsibilities: |

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|Job Title: |Date From: |Date To: |Hrs/Week: |Employer: |

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|Address: |Phone: |

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|Supervisor: |May we contact this employer? |

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|Reason for leaving? |Job Responsibilities: |

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Please insert two references. Each person utilized as a reference must complete a corresponding Letter of Recommendation form provided at the end this application. Submit Letter of Recommendation Forms with this packet in your Manilla envelop or folder. References are individuals who can affirm that you merit placement as a candidate for this program. You may ask coaches, teachers, church/religious affiliated individuals, supervisors, employers, etc.

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|References |

|Reference #1 Name and Title: |Email Address: |Phone: |

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|Reference #2 Name and Title: |Email Address: |Phone: |

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|Student Applicant Signature: |Date: |

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|I certify that all of the answers and statements on this application are true and complete to the best of my knowledge. I understand that should an investigation |

|disclose untruthful or misleading answers, my application may be rejected, my name removed from consideration, or my participation in the program terminated. |

Letter of Recommendation Form (1)

Student Name:______________________________________________________________________________________

The student above is applying for the Pharmacy Technician Program to become a Certified Pharmacy Technician. The student is expected to be responsible, dependable, considerate, and able to provide high quality care to all patients and personnel he or she encounters.

Please carefully consider the criteria listed below and offer your evaluation of this student. Thank you for taking the time to complete this recommendation. You may return this form to the student in a sealed envelope to submit with his or her application.

Please circle the appropriate rating (please comment briefly on any fair or poor rating):

Criteria: Rating: Comments:_______________

Conduct Excellent Good Fair Poor ________________________________

Dependability Excellent Good Fair Poor ________________________________

Follows instructions Excellent Good Fair Poor ________________________________

Accepts responsibility Excellent Good Fair Poor ________________________________

Shows initiative Excellent Good Fair Poor ________________________________

Works well with others Excellent Good Fair Poor ________________________________

Overall, do you recommend this student as an applicant for the Pharmacy Technician Program:( ) YES( ) NO

Additional Comments:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Your Name & Position:______________________________________________________________________________

Signature: ______________________________________________________ Date: ___________________________

Telephone # and Email Address: ______________________________________________________________________

If you have any questions, please contact:

Ava Lomache, RN, BSH, Pharmacy Technician Program Coordinator

Hopkins County Career and Technology Center

1775 Patriot Dr.

Madisonville, KY 42431

270-825-8998

ava.lomache@hopkins.kyschools.us

Letter of Recommendation Form (2)

Student Name:______________________________________________________________________________________

The student above is applying for the Pharmacy Technician Program to become a Certified Pharmacy Technician. The student is expected to be responsible, dependable, considerate, and able to provide high quality care to all patients and personnel he or she encounters.

Please carefully consider the criteria listed below and offer your evaluation of this student. Thank you for taking the time to complete this recommendation. You may return this form to the student in a sealed envelope to submit with his or her application.

Please circle the appropriate rating (please comment briefly on any fair or poor rating):

Criteria: Rating: Comments:_______________

Conduct Excellent Good Fair Poor ________________________________

Dependability Excellent Good Fair Poor ________________________________

Follows instructions Excellent Good Fair Poor ________________________________

Accepts responsibility Excellent Good Fair Poor ________________________________

Shows initiative Excellent Good Fair Poor ________________________________

Works well with others Excellent Good Fair Poor ________________________________

Overall, do you recommend this student as an applicant for the Pharmacy Technician Program:( ) YES ( ) NO

Additional Comments:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Your Name & Position:______________________________________________________________________________

Signature: ______________________________________________________ Date: ___________________________

Telephone # and Email Address: _______________________________________________________________________ __________________________________________________________________________________________________

If you have any questions, please contact:

Ava Lomache, RN, BSH, Pharmacy Technician Program Coordinator

Hopkins County Career and Technology Center

1775 Patriot Dr.

Madisonville, KY 42431

270-825-8998

ava.lomache@hopkins.kyschools.us

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