Medical Assisting Program Application

*Form has Required Fields

Date

Semester you are applying for

First Name

Middle

Last Name

List other names under which records may be found, including maiden names

Address

Apt

City/Town

State/Province

ZIP/Postal Code

Home Phone

Cell Phone

Work Phone

Friend/Relative (In case of emergency)

Name

Relationship

Phone

High School

Where Obtained

Year

College(s) attended

Name of School

City/State

Dates

# Hours

Name of School

City/State

Dates

# Hours

Name of School

City/State

Dates

# Hours

Name of School

City/State

Dates

# Hours

Are you or have you ever been on any academic probation or suspension?

Have you ever applied to this Medical Assisting program before?

Departmental interview date

Are you an honorably discharged military veteran (with DD-214)?

Upload the Following

Upload a copy of your Driver's License

Upload requirements

Front & back copy of your BLS Provider CPR card from the American Heart Association

Upload requirements

HESI LPN-ADN Specialty Entrance Exam Score Report from Evolve by Elsevier account

Photocopy of Official High School and College Transcripts after submitting to San Jacinto College Admissions

(All transfer coursework must be evaluated by San Jacinto College Admissions)

May submit unofficial San Jacinto College transcript from SOS/Student Account, if attended

Upload requirements

Proof of Minimum of 2.5 or higher GPA - Cumulative GPA from all previous colleges attended

Upload requirements

San Jacinto College Graduation Plan Strategy (GPS) Report from SOS Login/Student Account

Attached are the instructions for running the report. Questions for this should be referred to Admissions or Counseling (EPCC).

Upload requirements

Upload a copy of your Career Assessment - Focus 2

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Upload veteran’s DD214

Upload requirements

Upload Proof of Immunizations

Immunizations are the responsibility of the student and must be kept current during the entire program.

Tetanus (td booster/tdap) [within the past 10 years]
MMR titer or proof of required amount of immunizations for immunity
Varicella titer or proof of required amount of immunizations for immunity(History of the disease is NOT accepted)
HEP B titer that shows immunity
TB (PPD) skin test, Quantiferon test [within the past year] or chest x-ray [within past two years]
Seasonal flu shot [within the past year] or proof of allergy to the flu shot

Copies of Immunizations

Upload requirements

Proof of health insurance (front/back); Harris County Gold Card or Medicaid for pregnancy only are not accepted.

Upload requirements

Applicant Acknowledgement

I acknowledge that the information on this application is accurate, to the best of my knowledge. I understand that falsification of information provided will result in disqualification for admission.

Applicant Signature

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Date

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