DIALYSIS

Students must be 18 years of age or older, and admission is by this application. Only completed applications will be accepted. There are fourteen (14) spaces available. Registration fee is $218 which includes: $180 registration, $5 technology, $15 security, $2 accident insurance, and $16 malpractice insurance.

Training includes class, lab, and clinical experiences. The course is designed to prepare individuals with the theoretical, technical, and clinical skills needed to maintain equipment and provide patient care to those being treated for chronic renal diseases. Class format includes lecture, laboratory, and clinical activities. Successful completion prepares individuals for employment as a dialysis technician in hospitals, renal dialysis facilities, and clinics. After one year of work experience, individuals may be eligible to sit for national certification as a Clinical Hemodialysis Technician.

The Division of Continuing Education of Wilson Community College recognizes and is fully supportive of clinical agencies that choose to require a drug screening, background check, or fingerprinting on students. These tests are provided at no charge through Davita, Inc.

APPLICATION REQUIREMENTS

Completed and signed application with each of the following required copies attached. It is the student’s responsibility to obtain these copies. Wilson Community College will not make copies of required paperwork. Keep the original records and BRING COPIES ONLY.

Ø  High school diploma, NC High School Equivalency

Ø  North Carolina picture ID (example: driver’s license)

Ø  Proof of following immunizations:

·  TB skin test within the past nine (9) months of class start date

·  Two MMR (Mumps, Measles, Rubella)

·  Three Hepatitis B (at least the first shot prior to the start date is required)

·  Varicella injection or Titer (blood test to prove immunity to chicken pox)

·  Tdap (within the past 10 years)

·  Flu shot required

REQUIRED prior to clinical rotations:

UNIFORMS: Teal top and white pants, white lab coat, and white, closed-toe shoes. Skirts and/or dresses must be approved by Instructor of course prior to clinical rotation. Uniforms are available at Wilson Community College’s Bookstore.

DIALYSIS APPLICATION for SPRING “2018” (Section # 30303)

January 9th – April 19th

Tuesday and Thursday of each week

9:00 a.m. – 1:00 p.m.

Building: G Room: 109

Clinical Hours: 6:00 a.m. – 8:30 a.m. and 10:00 a.m. – 12:30 p.m.

The Program Coordinator will review and approve applications for those students who wish to pre-register. Applications will be available starting on October 5th. Students wishing to have applications approved are welcome to call 252-246-1325 for any questions regarding the approval process. Classes fill up quickly so pre-registration is encouraged. Once your application has been approved, you will be eligible to register and pay the $218 beginning November 6th. Registration will continue until January 8, 2018 or until the class is full. Mail-in applications will not be accepted.

NAME: Last: ______First: ______Middle Initial: ______

ADDRESS: ______City/State: ______Zip: ______

PHONE: Home: ______BIRTHDATE: ______Month ______Day ______Year

Cell: ______SEX: _____Male _____Female

RACE: ____White ____Black ____American Indian ____Hispanic ____Asian ____Other

EMPLOYMENT: ___Unemployed ___Part-Time ___Full-time EMPLOYER: ______

CAREER PLANS: ______

DO YOU HAVE PREVIOUS EXPERIENCE IN THE HEALTH FIELD? ___Yes ___No

IF YES, PLEASE LIST: ______

AGREEMENT

I have attached all required copies to my application; I have read, understand and agree to all stated requirements of the Dialysis program; I understand the required clinical dress code, and agree to comply upon acceptance; I understand this is an application only and does not constitute acceptance into the program; and understand I will be dismissed from the program if documented as verbally or physically abusive to college administration, clinical site staff, patients, or visitors.

SIGNATURE: ______DATE: ______

THIS MUST BE SIGNED AND WITNESSED AT TIME OF REGISTRATION: If any facility prohibits the student from participating in the clinical experience, the student will be dismissed due to an inability to progress and complete the program.

______

Student’s signature Signature of Witness Date