Transcription
PharmacyTechnicianApplicationHEALTH
ALVIN COMMUNITY COLLEGE ASSOCIATEAPPLIED SCIENCE DEGREEPHARMACY TECHNICIAN PROGRAMAPPLICATION FOR ADMISSION(Please print in ink or type)Last Name ACC Student ID#First NameMiddle NameSuffix (Jr., II, etc)Other last namesyou have hadMailing AddressStreet , PO Box, rural route, etcCityStateZipPermanent Address (If different)Street, PO Box, rural route, etcCityStateZipHome phone # ( ) -Work phone # ( ) -Mobile phone # ( ) -Pager # ( ) -County of residenceE-mailEmergency Notification (spouse, parent, guardian, etc):AddressStreetCitizenship:CityU.S. CitizenStateTelephone # ( ) -ZipPermanent Resident AlienPERMANENT RESIDENT ALIEN INFORMATIONCountry of CitizenshipInternational StudentResident Card NumberAre you currently enrolled in a college or university?YESNOIf yes , name of institution & city/state:List all courses in which you are currently enrolled:COLLEGES / UNIVERSITIES ATTENDED (Vocational, 2-year and/or 4-year)School name/city/stateMajor & Degree earnedDates attendedCREDENTIALS / LICENSESDo you have any of the following degrees::Associate Degree NursingRespiratory CareElectroneurodiagnosticNational RegistryParamedicTypeInstitution nameCityStateDates attendedAlvin Community College Pharmacy Technician Program3110 Mustang Road, S108, Alvin, Texas 77511 (281) 756.5610
I certify that information given on this application is correct and complete to the best of my knowledge. I understand that missrepresentation or omission of information will make me ineligible for admission to, or continuation in, the Alvin Community CollegePharmacy Technician Program. If applying online, signature will be obtained at an information meeting. I understand that an offerof admission will require compliance with the Activity Standards and Immunization Requirements outlined in this application. Iunderstand that if selected for admission to this program, my acceptance is conditional on successfully completing a backgroundcheck conducted by Alvin Community College. I understand that my acceptance to the program is contingent upon the successfulcompletion of any outstanding prerequisites (if applicable) and that verification must be provided to the program prior tomatriculation. I understand that all documents submitted to Alvin Community College will be retained permanently by the Programregardless of my admission status.Legal signature of applicantDateReturn this form to pharmacytech@alvincollege.eduAlvin Community College Pharmacy Technician Program3110 Mustang Road, S108, Alvin, Texas 77511 (281) 756.5610
ALVIN COMMUNITY COLLEGEPHARMACY TECHNICIANPROGRAMCONSENT FOR RELEASE OF INFORMATION(Initial)My signature below indicates that I have read the policy on Criminal BackgroundScreening for the Pharmacy Technician program. This form provides my consent for theresults of criminal background checks to be released to the Alvin Community Collegeprogram director. I certify that I do not have any criminal history that would disqualify mefrom a clinical rotation or prevent me from obtaining Pharmacy Technician licensure.DRUG SCREEN(Initial)My signature below certifies that I have read, understand and agree to accept the AlvinCommunity College Health Program’s Policy for Drug Screening.TECHNICAL STANDARDS - ACKNOWLEDGEMENTPHYSICAL REQUIREMENTS/WORKING CONDITIONS(Initial)I acknowledge receipt of the form Technical Standards for Pharmacy Technicianoutlining the physical requirements of the training program and the duties of thePharmacy Technician Program at Alvin Community College.By my signature below, I confirm my physical ability to fulfill the responsibilities of theprogram and any positions which I may be offered following graduation with or withoutreasonable accommodation.Prospective Student's Name (Print):Prospective Student's Signature:Date:Return this form pharmacytech@alvincollege.eduAlvin Community College Pharmacy Technician Program3110 Mustang Road, S108, Alvin, Texas 77511 (281) 756.5610
Pharmacy Technician ProgramPERSONAL STATEMENT(Please attach a separate sheet of paper if necessary)1.Please explain in your own words why you wish to enroll in the Pharm Tech Program.2.Please tell us about experiences in your life that have led you to a career in health care.Return this form to pharmacytech@alvincollege.eduAlvin Community College Pharmacy Technician Program3110 Mustang Road, S108, Alvin, Texas 77511 (281) 756.5610
Letter of ReferenceApplicant:Following is a list characteristic which we feel are required for a student to successfullycomplete a training program in the Pharmacy Technician Program. We wouldappreciate your cooperation in completing this form, and returning it to the College atyour earliest convenience.3.More than satisfactory2.Satisfactory1.UnsatisfactoryNONot observed, or no basis for ependent WorkCommunication-VerbalWrittenStress ResponseAttitudeManual DexterityGroup tyKnowledge/ApplicationDecision MakingDependability21NOAccountable for one’s actionsHas the capacity to direct the activities of othersMotivated to pursue actions independentlyCapable of responding or conforming to changing or newsituationArranges by systematic planning for optimal efficiencyAssured in one’s abilities & skillsCompletes tasks with minimal supervisionContributes knowledge & opinions in an articulate mannerExpresses self clearly in writingMaintains composure/able to functionPositive approach to work/coworkersAbility to perform psychomotor skillAbility to get along with peers and coworkerAbility to get along/teachers/supervisorsDemos common sense, tact, empathy to patientAbility to apply theory to practiceAbility to analyze problem/formulate solutionFollows through on assignmentsAdditional information – Use to amplify or add to characteristics rated previously. Pleaseindicate applicant’s strengths and those qualities that require further development.StrengthsQualities that require further development.Return this form to pharmacytech@alvincollege.eduAlvin Community College Pharmacy Technician Program3110 Mustang Road, S108, Alvin, Texas 77511 (281) 756.5610
Page 2: Letter of ReferenceRelationship to applicantAdvisorTeacherSupervisorother: Please indicateHow long have you known the applicant?How well do you know applicant?Do you Highly RecommendRecommendRecommend with ReservationsNot ress:Telephone Number: ( )Please return this evaluation form to:pharmacytech@alvincollege.eduAlvin Community CollegePharmacy Technician3110 Mustang RoadAlvin, TX 77511-4898Return this form to pharmacytech@alvincollege.eduAlvin Community College Pharmacy Technician Program3110 Mustang Road, S108, Alvin, Texas 77511 (281) 756.5610
Letter of ReferenceApplicant:Following is a list characteristic which we feel are required for a student to successfullycomplete a training program in the Pharmacy Technician Program. We wouldappreciate your cooperation in completing this form, and returning it to the College atyour earliest convenience.3.More than satisfactory2.Satisfactory1.UnsatisfactoryNONot observed, or no basis for ependent WorkCommunication-VerbalWrittenStress ResponseAttitudeManual DexterityGroup tyKnowledge/ApplicationDecision MakingDependability21NOAccountable for one’s actionsHas the capacity to direct the activities of othersMotivated to pursue actions independentlyCapable of responding or conforming to changing or newsituationArranges by systematic planning for optimal efficiencyAssured in one’s abilities & skillsCompletes tasks with minimal supervisionContributes knowledge & opinions in an articulate mannerExpresses self clearly in writingMaintains composure/able to functionPositive approach to work/coworkersAbility to perform psychomotor skillAbility to get along with peers and coworkerAbility to get along/teachers/supervisorsDemos common sense, tact, empathy to patientAbility to apply theory to practiceAbility to analyze problem/formulate solutionFollows through on assignmentsAdditional information – Use to amplify or add to characteristics rated previously. Pleaseindicate applicant’s strengths and those qualities that require further development.StrengthsQualities that require further development.Return this form to pharmacytech@alvincollege.eduAlvin Community College Pharmacy Technician Program3110 Mustang Road, S109, Alvin, Texas 77511 (281) 756.5610
Page 2: Letter of ReferenceRelationship to applicantAdvisorTeacherSupervisorother: Please indicateHow long have you known the applicant?How well do you know applicant?Do you Highly RecommendRecommendRecommend with ReservationsNot ress:Telephone Number: ( )Please return this evaluation form to:pharmacytech@alvincollege.eduAlvin Community CollegePharmacy Technician3110 Mustang RoadAlvin, TX 77511-4898Return this formAlvin Community College Pharmacy Technician Program3110 Mustang Road, S108, Alvin, Texas 77511 (281) 756.5610
Alvin Community College Pharmacy Technician Program 3110 Mustang Road, S109, Alvin, Texas 77511 (281) 756.5610 . Letter of Reference ; Applicant: _ Following is a list characteristic which we feel are required for a student to successfully complete a training program in the Pharmacy Technician Program. .
