SFCC PHLEBOTOMY PROGRAM

GENERAL INFORMATION AND PHLEBOTOMY APPLICATION CHECKLIST

General Information:

The Phlebotomy program consists of four courses, and once approved for the program, you register for all 4 courses at the same time:

PHLB 113 and PHLB 115L: 6 credit hours, First 8 weeks of semester; Meet T and Th from 3PM to 8:30PM

PHLB 116L and PHLB 117: 6 credit hours, Second 8 weeks of semester; Clinical Externship (PHLB 116L) hours arranged; PHLB 117 meets T from 6PM-8:30 PM

Note: For the clinical externship:

Students complete 100 hours and 100 successful draws in approved laboratories during the second 8 weeks

Students should plan to devote about 12-15 hours/week during the 8 week externship

Clinical hours will be between 8 and 5PM, M-F only. No weekends and evenings are available

Students may have to provide own transportation to clinical sites, which may be in Santa Fe, Los Alamos, Espanola, etc.

Phlebotomy Application Checklist:

  1. _____Applied to SFCC (you have an “A” number)
  1. _____Completed application for Phlebotomy Program and submitted it on time
  1. _____Attached transcript (unofficial or official) showing completion and grade for college level Medical Terminology
  1. _____Able to meet internship clinical hours requirement (only hours available are available M-F, 8-5, no evenings or weekends)
  1. _____Able to submit copy of government issued photo ID as required for Background check

SANTA FE COMMUNITY COLLEGE

Phlebotomy Program

APPLICATION FOR ADMISSION—Due on or before October 23, 2015

______

Date of Application

Please print in ink and answer all questions

Name:______

(Last) (First-legal) (Middle Initial) (Maiden)

Mailing Address:______

Street/P.O. Box City State Zip Code

Telephone: ______

(Home) (Work/Message)

Cell phone:______E-mail address:______

Person to contact in case of emergency:______Relationship:______Phone #______

High School last attended:______

Name of School City/State

Did you graduate? Yes ____ No ____ If no, GED? ____(Official transcript must be on file.)

Colleges attended, including SFCC. (Official transcripts must be on file for each college except SFCC)

COLLEGE City/State Units/Credits GPA Degree Earned

Completed

I am (check one):

_____ Currently enrolled at SFCC _____ Transferring to SFCC from another college

College level Medical Terminology coursecompleted: Yes_____ No______

Have you been licensed or certified to practice in any field of health care? Yes _____ No _____

If yes, please describe:

Licensed/Certified as: ______Date Licensed/Certified: ______Expiration date: ______

If no, do you have any medical experience (Include internships, caregiver, work, etc.) Yes ___ No ____

If yes, please briefly describe:

Have you ever been convicted of a felony?Yes _____ No _____

NOTE: Individuals who have been convicted of a felonymay notbe eligible for licensure or certification in the health care field. It is theapplicant’s responsibility to contact the licensing board or certifying agency inthe state where he/she plans to seek licensure toverify eligibility for licensure or certification prior to making application to the program.

RESIDENCY DATA: Please list below your places of residence (including dates) for the past 10years.

Street AddressCityState Dates

______

______

______

STATISTICAL DATA (Used for accreditation purposes only)

The items listed below are for statistical purposes only and are not used in the determination ofeligibility for admission to the Phlebotomy Program.

Gender: Female ____ Male ____Date of Birth______

Ethnicity: Native American/Alaskan Native ____ Native Hawaiian/Other Pacific Islander _____

African American/Black _____ Hispanic/Latin _____

White _____ Asian _____ Other ______

Santa Fe Community College is committed to providing equal education and employment opportunity regardless of gender, maritalstatus, sexual orientation, color, race, religion, age, national origin or disability. Equal educational opportunity applies to admission, recruitment, extracurricular programs and activities, access to course offerings, counseling, testing, and financial assistance

Employment History (May attach resume instead of completing this table)

Name of Employer / City / State / Date from / Date to / Responsibilities / Number of Hours/
week

I CERTIFY THAT ALL THE STATEMENTS IN THIS APPLICATION ARE CORRECT AND TRUE.

______

SignatureDate

Submit completed application (with official or unofficial copy of transcript) in one of three ways:

Mail to: Director of Medical Assisting and Phlebotomy Program,Santa Fe Community College, 6401 Richards

Avenue, Santa Fe NM 87508

Fax to: Director of the Medical Assisting and Phlebotomy Program; 505-428-1526

Deliver to: Director of Medical Assisting and Phlebotomy Program; Room 470; Santa Fe Community College,

6401 Richards Avenue, Santa Fe NM 87508