University of Texas at Arlington
[pic]
Health Careers Institute
Division for Enterprise Development 140 W. Mitchell St. Arlington, Texas 76019 817-272-2581
Healthcare Program Application
|Last Name |First Name |Middle Initial |
|Mailing Address |City |State |Zip Code |
|Home Phone |Cell Phone |
|Email Address |
|Social Security No. |Date of Birth |Gender |
| | |Male |
| | | |
| | |Female |
|Citizenship |
| |
|(Please mark one) |
| |
|U.S. Citizen Yes No If no, Citizenship of _________________________ |
| |
|Permanent Resident Yes No |
|Previous Education |
| |
| |
|Do you have a High School Diploma/GED? Yes No If no, the highest grade completed _________ |
| |
|Additional Education:___________________________________ |
| |
|Healthcare Training:____________________________________ |
|Training Program Interest |
| |
| |
|Certified Nurse Aide EKG Technician Phlebotomy Technician |
| |
|Patient Care Technician Dental Assistant Pharmacy Technician |
| |
|Medical Administrative Asst. Medical Coding & Billing Veterinary Assistant |
| |
|Other ________________________________________ |
|Health Questionnaire |
| |
|Do you have any physical limitations which would affect your ability Yes No |
|to lift, turn, or transfer patients? |
| |
|Do you have any limitations in use of your senses, such as in sight or Yes No |
|hearing, which would limit your ability to practice a health profession? |
| |
|Do you have any other condition which might interfere with your ability Yes No |
|to practice a health profession? |
| |
|If you have answered “Yes” to any of the above questions, please explain your limitations in detail in the space provided below. |
|Additional Information |
| |
|Do you have health insurance? Yes No |
| |
|How did you hear about UT Arlington’s Continuing Education? |
| |
|Friend Employment News Green Sheet Continuing Education Catalog |
| |
|UTA Website Other ______________________________ |
|Emergency Contact |
|Last Name |First Name |Middle Initial |
|Mailing Address |City |State |Zip Code |
|Contact Phone Number |Relationship |
|APPLICANT STATEMENT AND SIGNATURE |
|I understand that I am responsible for the information provided in this application. I have submitted information that is completely true and |
|correct. I understand that any information that is not true may cause me not to be accepted in the training program or to be dismissed from the |
|program. I understand that upon acceptance of enrollment into the healthcare program of my choice, a criminal background check, immunization |
|record, and drug screen may be required. I also understand that if I am not accepted for training or if I decide not to attend, my application |
|will be destroyed. |
| |
|Applicant Signature_____________________________________________________ Date_____________________ |
|For Office Use Only |
| |
|Admissions Advisor’s Signature___________________________________________ Date_____________________ |
| |
|Applicant Accepted? Yes No If no, Reason for Denial______________________________ |
| |
|_________________________________________________ |
| |
|Bidsheet Submitted? Yes No Agency___________________________________________ |
| |
|Date______________________________________________ |
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