RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE
                          PHYSICIAN ASSISTANT PROGRAM...
□     ENTRY DATA FORM: Complete and enclose with your Program application. The information submitted on the
      Entry Da...
RIVERSIDE COUNTY REGIONAL MEDICAL CENTER / RIVERSIDE COMMUNITY COLLEGE
                                 PHYSICIAN ASSISTAN...
Name:                                                          SS #:

SKILLS:
Check all items that are or have been part o...
Name:                                                    SS #:


MILITARY SERVICE:

Job Title:                            ...
Name:                                                                     SS #:

CHARACTER AND FITNESS FOR LICENSURE:
    ...
Name:                                                                SS #:


PERSONAL STATEMENT: Use this page for a typed...
Name:                                                                      SS #:

 PREREQUISITE COURSES:

 List all comple...
Name:                                                                  SS #:

Please Note: Errors, omissions, or falsifica...
RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE
                       PHYSICIAN ASSISTANT PROGRAM
  ...
Applicant Name:                                                               SS #:

TO BE COMPLETED BY THE EVALUATOR:
If ...
RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE
                       PHYSICIAN ASSISTANT PROGRAM
  ...
Applicant Name:                                                               SS #:

TO BE COMPLETED BY THE EVALUATOR:
If ...
RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE
                       PHYSICIAN ASSISTANT PROGRAM

 ...
RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE
                       PHYSICIAN ASSISTANT PROGRAM


...
RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE
                       PHYSICIAN ASSISTANT PROGRAM


...
RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE
                       PHYSICIAN ASSISTANT PROGRAM

 ...
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RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY ...

  1. 1. RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE PHYSICIAN ASSISTANT PROGRAM 2008 APPLICATION FOR ADMISSION APPLICATION CHECKLIST Name: SS #: Please read and follow instructions carefully. Use only the forms provided in this application packet. The following must be submitted as one packet to the RCRMC/RCC PA Program (this sheet must be included in your application packet). Items submitted under separate cover will not be accepted. □ APPLICATION: Complete, sign and date the application. Any falsification, omission, or misrepresentation will negate an application being reviewed or considered. Leave nothing blank--if an area does not apply to you, indicate N/A. Do Not submit your resume to substitute for or as an addendum to any portion of the application. □ PERSONAL STATEMENT: On the form provided, include a typed, double-spaced, One page (500 Word), personal statement that explains your professional goals, reasons for wanting to be a physician assistant and your commitment to the profession. Font size less than 10 will not be accepted. Failure to comply with these directions will result in rejection of your entire application. □ VERIFICATION OF OCCUPATIONAL EXPERIENCE: Include forms from each employer you list on the direct, patient care experience section of the application. Do not complete any portion of this form yourself. Forms must have the original signature of the person verifying your experience. No faxes or photocopies will be accepted. □ OFFICIAL TRANSCRIPTS: Must be included in your application packet. Submit official transcripts, no more than 90-days old, from all colleges and universities attended. If the applicant has attended Riverside Community College, RCC Transcripts must be submitted along with this application. This is required whether related to the Physician Assistant Program prerequisites or not, whether U.S. or not, regardless of attendance, whether the work was completed or whether transcripts were previously submitted to the college for any other purpose. All transcripts must be in sealed institution envelopes. Open envelopes or copies are not acceptable, will not be considered, and will impact your application. A detailed transcript evaluation must be ordered from American Evaluation Research Corp. (www.aerc-eval.com) or International Education Research Foundation (www.ierf.org) to accompany any transcript that is from outside of the U.S. All required coursework must be completed and reported on the transcript when submitted. □ RCRMC/RCC PA PROGRAM REFERENCE FORMS: Reference Forms are required from two (2) individuals (physician, physician assistant, nurse supervisors, etc.) who have supervised the applicant in the workplace. The PA Program reference form must be signed, placed in an envelope that has been sealed and signed across the back flap by the evaluator, and returned as part of the application packet. Only reference forms with original signatures will be accepted. Attachments will not be accepted or considered. Please inform your reference of the specific requirements. Failure to comply will result in rejection of your entire application. □ RCC ADMISSION APPLICATION: If you are not currently an RCC student it will be necessary for you to complete the online application for admission to Riverside Community College (http://rcc.edu) Click on Web Advisor to apply online prior to submitting the RCRMC/RCC Physician Assistant Program application. Please print and submit a copy of the confirmation page with this application. 1
  2. 2. □ ENTRY DATA FORM: Complete and enclose with your Program application. The information submitted on the Entry Data form is confidential and used for applicant demographics only. See page 16 for detailed instructions. I have submitted all required data and have indicated which items do not apply to me. I understand that I am responsible for submitting the required data and that the RCRMC/RCC Physician Assistant Program is under no obligation to notify me of missing material. I understand that all application materials become the sole property of the RCRMC/RCC Physician Assistant Program and that the RCRMC/RCC PA Program reserves the right to verify any information related to my application. I understand that my completed application packet to the Program is submitted at my expense. I understand that information provided by me on the Entry Data Form may be used for research purposes. I understand that the RCRMC/RCC Physician Assistant’s program has procedures in place to protect the anonymity and confidentiality of the information provided on the Entry Data Form. Applicant Signature: Date: 2
  3. 3. RIVERSIDE COUNTY REGIONAL MEDICAL CENTER / RIVERSIDE COMMUNITY COLLEGE PHYSICIAN ASSISTANT PROGRAM 2008 ENROLLMENT APPLICATION USE ONLY THE FORMS PROVIDED, DO NOT DUPLICATE UNLESS OTHERWISE INDICATED. TYPE OR PRINT LEGIBLY IN BLACK INK. Name (Last, First, M.I.): Other name(s) used: SS#: Gender: Male ___ Female ___ Date of Birth: / / Place of Birth: Address: City: County: State: Zip code: Mailing address: Home phone: ( ) Cell/Msg/Pager: ( ) Email: Current employer: Supervisor: Address: Phone: IT IS YOUR RESPONSIBILITY TO ADVISE THE PROGRAM OF ANY ADDRESS/PHONE NUMBER CHANGES. EDUCATION: (If additional space is needed, please attach a separate sheet.) College: State: From: To: Major: Units completed: (qtr) (smstr) GPA: Degree received: AA AS BA BS MA/MS PhD Other: College: State: From: To: Major: Units completed: (qtr) (smstr) GPA: Degree received: AA AS BA BS MA/MS PhD Other: College: State: From: To: Major: Units completed: (qtr) (smstr) GPA: Degree received: AA AS BA BS MA/MS PhD Other: TOTAL UNITS COMPLETED: (qtr) (smstr) Cumulative GPA: High School: Address: Vocational/Allied Health School: Degree/Certificate/Diploma: Year completed: 3
  4. 4. Name: SS #: SKILLS: Check all items that are or have been part of your job responsibilities: □ Medical history-taking □ Patient education □ Physical examination □ Physical therapy □ Vital signs □ Respiratory therapy □ First aid □ Splinting and/or casting □ Cardiopulmonary resuscitation □ Suture removal □ EKG interpretation □ Suturing □ Bacterial culture interpretation Microscopic evaluation of: □ Gastric lavage □ Taking x-rays □ Blood □ Injections □ Urine □ Venipuncture □ Gram-stained specimens □ Catheterization □ Other PAID, DIRECT PATIENT CARE EXPERIENCE: List all clinical work completed and calculate the total hours (e.g., 40 hrs/wk x 50 weeks = 2000 hours.) Attach a separate sheet if necessary. A Verification of Occupational Experience form (see page 14 in this document) must be submitted for each employer listed below. Job Title: Total hours: From: To: Employer: Supervisor: Phone: Address: City: State: Zip: Description of duties: Job Title: Total hours: From: To: Employer: Supervisor: Phone: Address: City: State: Zip: Description of duties: Job Title: Total hours: From: To: Employer: Supervisor: Phone: Address: City: State: Zip: Description of duties: 4
  5. 5. Name: SS #: MILITARY SERVICE: Job Title: Location: From: To: Job Title: Location: From: To: Discharge Date: Type of Discharge: (Please attach a copy of your DD214.) CURRENT LICENSES/CERTIFICATIONS: Title: State: Date issued: Expires: Title: State: Date issued: Expires: Title: State: Date issued: Expires: 5
  6. 6. Name: SS #: CHARACTER AND FITNESS FOR LICENSURE: (Circle One) 1. Have you ever been enrolled in any other PA program? Yes No 2. Have you ever been convicted of a crime (other than for a minor traffic violation)? Yes No 3. Have you ever been disciplined, received an academic warning, been placed on Yes No probation or dismissed in connection with your academic performance or other reason? 4. Have you ever been disciplined, sanctioned, placed on probation, dismissed or had a Yes No judgment against you in connection with any misconduct matter, including educational, personal, professional, military, business, or employment behavior or activity? IF YOU ANSWERED YES TO ANY OF THE QUESTIONS ABOVE, GIVE A DETAILED EXPLANATION IN THE SPACE BELOW. PLEASE USE AN ADDITIONAL SHEET IF NECESSARY. 6
  7. 7. Name: SS #: PERSONAL STATEMENT: Use this page for a typed, double-spaced, 500 word, personal statement that explains your professional goals, reasons for wanting to be a physician assistant and your commitment to the profession. Your statement must be printed on this form. A font size less than 10 will not be accepted. Failure to comply with these directions will result in rejection of your entire application. 7
  8. 8. Name: SS #: PREREQUISITE COURSES: List all completed prerequisites below. Do not list courses in progress. College/Univ. Write Department Name Sem./Qtr. Year/Term Final Prerequisites Where Taken Course Number & Complete Course Title Units Taken Grade *Anatomy and Physiology 2A *Anatomy Lab *Anatomy and Physiology 2B *Physiology Lab *Microbiology 1 *Microbiology Lab Physics 10 Physics 11 Chemistry 2A Psychology 1 Sociology 1 or Anthropology 2 English 1A Math 35 Advisories: Psychology 35 Medical Terminology 1A * Anatomy and Physiology and Microbiology must include a lab, and have been taken within five years of application. THIS LIST IS ONLY A GUIDELINE. ALL COURSE WORK WILL BE REVIEWED FOR ACCEPTABILITY AND ACCURACY. 8
  9. 9. Name: SS #: Please Note: Errors, omissions, or falsification in any part of the application or supporting materials will result in ineligibility in the application process. CERTIFICATION I certify that all responses to the questions and any information given herein are my own. For the purpose of determining admission, I hereby consent to and authorize any educational institution I have attended to release any academic and/or disciplinary information to the RCRMC/RCC PA Program. I understand that information submitted relative to this application becomes property of the RCRMC/RCC PA Program. I further understand that the RCRMC/RCC PA Program reserves the right to verify any or all data that I or others have provided, whether solicited by me or not. Applicant Signature: Date: APPLICATION DEADLINE: August 31, 2008 APPLICATIONS MUST BE MAILED DIRECTLY TO THE RCRMC/RCC PHYSICIAN ASSISTANT PROGRAM AT THE ADDRESS BELOW. DO NOT HAND-CARRY APPLICATION PACKETS TO THE RCRMC/RCC PA PROGRAM. APPLICATION MUST BE POSTMARKED NO LATER THAN AUGUST 31, 2008. Note: If you send your application with signature required, it may result in serious delay of our receipt of your packet. APPLICATIONS POSTMARKED AFTER THE DEADLINE DATE WILL NOT BE ACCEPTED. ADDRESS ALL CORRESPONDENCE TO: Riverside Community College RCRMC/RCC PA PROGRAM 16130 Lasselle Street Moreno Valley CA 92551-2045 We comply with Titles VI and VII of the Civil Rights Act of 1994, Title IX of the Education Amendments of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, Sections 102 and 103 of the Americans with Disabilities Act of 1990. We do not discriminate on the basis of race, color, national origin, religion, handicap, or sexual orientation in any of our policies, procedures, or practices. 9
  10. 10. RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE PHYSICIAN ASSISTANT PROGRAM 2008 APPLICANT REFERENCE FORM Dear Evaluator: Please return this reference form directly to the applicant in a sealed envelope with your signature across the sealed flap. This form must be included with the applicants packet. Applicant Reference forms can only be filled out by individuals who have supervised the applicant in the workplace. Do not mail the reference form directly to the RCRMC/RCC PA Program. Only reference forms with original signatures will be accepted. No attachments will be accepted or considered. Failure to comply with these directions will result in rejection of the entire application. Because of federal legislation giving students access to educational records, the RCRMC/RCC PA Program cannot guarantee the confidentiality of your comments unless the applicant has signed the Waiver of Applicant Right to Access below. WAIVER OF APPLICANT RIGHT TO ACCESS I hereby freely and voluntarily waive my right to access to information contained on this evaluation form and agree that the statement shall remain confidential. Applicant Signature: Date: Applicant's Name: SS #: Last First M.I. Mailing Address: Street City State Zip EVALUATOR PLEASE CHECK ONE APPLICANT HAS MY HIGHEST RECOMMENDATION I RECOMMEND THE APPLICANT WITH CONFIDENCE I RECOMMEND THE APPLICANT WITH SOME RESERVATIONS I DO NOT RECOMMEND THE APPLICANT Signature: Date: Print Name: Title: Institution: Phone: Address: If you have any questions, please contact the RCRMC/RCC PA Program at (951) 571-6166 10
  11. 11. Applicant Name: SS #: TO BE COMPLETED BY THE EVALUATOR: If the applicant has waived his/her right to access to materials (see above), this document remains a confidential communication between the evaluator and the RCRMC/RCC PA Program. How long have you known the applicant? From: To: Relationship to applicant: Employer Supervisor (in the workplace) ________ May a Program representative contact you for additional information? Yes No Please comment on the strengths and weaknesses of the candidate according to your knowledge of him/her in the following areas: Maturity: Emotional Stability: Learning Ability: Interpersonal Skills: Clinical Skills: Additional Comments: Signature/Title: Date: This form becomes the sole property of the RCRMC/RCC Physician Assistant Program. Only reference forms with original signatures will be accepted. No attachments will be accepted or considered. Failure to comply with these directions will result in rejection of the entire application. 11
  12. 12. RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE PHYSICIAN ASSISTANT PROGRAM 2008 APPLICANT REFERENCE FORM Dear Evaluator: Please return this reference form directly to the applicant, in a sealed envelope with your signature across the seal, to be included with his/her application packet. Applicant Reference forms can only be filled out by individuals who have supervised the applicant in the workplace. Do not mail the reference form directly to the RCRMC/RCC PA Program. Only reference forms with original signatures will be accepted. No attachments will be accepted or considered. Failure to comply with these directions will result in rejection of the entire application. Because of federal legislation giving students access to educational records, the RCRMC/RCC PA Program cannot guarantee the confidentiality of your comments unless the applicant has signed the Waiver of Applicant Right to Access below. WAIVER OF APPLICANT RIGHT TO ACCESS I hereby freely and voluntarily waive my right to access to information contained on this evaluation form and agree that the statement shall remain confidential. Applicant Signature: Date: Applicant's Name: SS #: Last First M.I. Mailing Address: Street City State Zip EVALUATOR PLEASE CHECK ONE APPLICANT HAS MY HIGHEST RECOMMENDATION I RECOMMEND THE APPLICANT WITH CONFIDENCE I RECOMMEND THE APPLICANT WITH SOME RESERVATIONS I DO NOT RECOMMEND THE APPLICANT Signature: Date: Print Name: Title: Institution: Phone: Address: If you have any questions, please contact the RCRMC/RCC PA Program at (951) 571-6166 12
  13. 13. Applicant Name: SS #: TO BE COMPLETED BY THE EVALUATOR: If the applicant has waived his/her right to access to materials (see above), this document remains a confidential communication between the evaluator and the RCRMC/RCC PA Program. How long have you known the applicant? From: To: Relationship to applicant: Employer ______ Supervisor (in the workplace) May a Program representative contact you for additional information? Yes No Please comment on the strengths and weaknesses of the candidate according to your knowledge of him/her in the following areas: Maturity: Emotional Stability: Learning Ability: Interpersonal Skills: Clinical Skills: Additional Comments: Signature/Title: Date: This form becomes the sole property of the RCRMC/RCC Physician Assistant Program. Only reference forms with original signatures will be accepted. No attachments will be accepted or considered. Failure to comply with these directions will result in rejection of the entire application. 13
  14. 14. RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE PHYSICIAN ASSISTANT PROGRAM VERIFICATION OF OCCUPATIONAL EXPERIENCE PLEASE COMPLETE THIS FORM IN ITS ENTIRETY. Each statement must be completed and signed by an employer or other official person, from the employing agency, having knowledge of the applicant's experience. Please do not accept this form if any portion of it has been completed by the applicant. Self-employment may be verified by a notarized affidavit and some corroboration such as tax statements from the company bookkeeper, accountant, attorney, or other such person. This statement verifies the occupational experience of: Name: Title: First M.I. Last Dates of Employment: From (month/year) To (month/year) Was employment paid? Yes No If No, Please explain: Was employment full-time? Yes No If No, please give percentage/hours: *Employment Responsibilities (please include specific tasks performed): Name of person verifying this form (Please print/type): Signature: Date: Title: Phone: Name of Business/Organization: Address: * This section must be completed for verification of the applicant's experience. 14
  15. 15. RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE PHYSICIAN ASSISTANT PROGRAM VERIFICATION OF OCCUPATIONAL EXPERIENCE PLEASE COMPLETE THIS FORM IN ITS ENTIRETY. Each statement must be completed and signed by an employer or other official person, from the employing agency, having knowledge of the applicant's experience. Please do not accept this form if any portion of it has been completed by the applicant. Self-employment may be verified by a notarized affidavit and some corroboration such as tax statements from the company bookkeeper, accountant, attorney, or other such person. This statement verifies the occupational experience of: Name: Title: First M.I. Last Dates of Employment: From (month/year) To (month/year) Was employment paid? Yes No If No, Please explain: Was employment full-time? Yes No If No, please give percentage/hours: *Employment Responsibilities (please include specific tasks performed): Name of person verifying this form (Please print/type): Signature: Date: Title: Phone: Name of Business/Organization: Address: * This section must be completed for verification of the applicant's experience. 15
  16. 16. RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE PHYSICIAN ASSISTANT PROGRAM VERIFICATION OF OCCUPATIONAL EXPERIENCE PLEASE COMPLETE THIS FORM IN ITS ENTIRETY. Each statement must be completed and signed by an employer or other official person, from the employing agency, having knowledge of the applicant's experience. Please do not accept this form if any portion of it has been completed by the applicant. Self-employment may be verified by a notarized affidavit and some corroboration such as tax statements from the company bookkeeper, accountant, attorney, or other such person. This statement verifies the occupational experience of: Name: Title: First M.I. Last Dates of Employment: From (month/year) To (month/year) Was employment paid? Yes No If No, Please explain: Was employment full-time? Yes No If No, please give percentage/hours: *Employment Responsibilities (please include specific tasks performed): Name of person verifying this form (Please print/type): Signature: Date: Title: Phone: Name of Business/Organization: Address: * This section must be completed for verification of the applicant's experience. 16
  17. 17. RIVERSIDE COUNTY REGIONAL MEDICAL CENTER/RIVERSIDE COMMUNITY COLLEGE PHYSICIAN ASSISTANT PROGRAM 2008 APPLICATION CHECKLIST Please use this checklist to ensure that you have completed the requirements for your application, you will not be notified of any materials missing from your application packet. Items submitted under separate cover will not be accepted. PLEASE KEEP THIS CHECKLIST FOR YOUR RECORDS. Applications to the RCRMC/RCC Physician Assistant Program must be submitted as one packet and mailed directly to the RCRMC/RCC PA Program. Applications must be postmarked no later than August 31, 2008. Do not hand-carry application packets to the RCRMC/RCC PA Program. Note: If you send your application with signature required, it may result in serious delay of our receipt of your packet. □ Completed RCRMC/RCC Physician Assistant Program Application. Leave nothing blank--if an area does not apply to you, indicate N/A. □ Personal Statement on form provided only. Follow directions carefully. □ Verification of Occupational Experience form from each employer that is listed on the direct patient care section of the application form. All forms must have the original signature of the person completing the form. Faxes/photocopies will not be accepted. □ Official transcripts, no more than 90-days old, from all colleges and universities attended. This is required whether related to the Physician Assistant Program prerequisites or not, whether U.S. or not, regardless of attendance, whether the work was completed or whether transcripts were previously submitted to the college for any other purpose. If the applicant has attended Riverside Community College, RCC transcripts must be submitted along with the application. Transcripts must be included in the application packet. A transcript evaluation is required to accompany any transcripts from outside the U.S. □ Two RCRMC/RCC Physician Assistant Program Reference Forms, sealed in an envelope with the evaluator's signature across the back flap. Only use forms provided. Forms must be completed by individuals who have supervised the applicant in the workplace. The individual must be familiar with your medical experience and must have their original signature. Faxes/photocopies will not be accepted. □ Riverside Community College Admission Application Verification form. APPLICATION TO RIVERSIDE COMMUNITY COLLEGE IS REQUIRED IF YOU ARE NOT A CURRENT RIVERSIDE COMMUNITY COLLEGE STUDENT. □ Entry Data Form. Please complete and enclose with your Program application, use School ID number 077, Health Science Program number 068, and the semester and year you enter the program will be Fall 2008. The information on the Entry Data form is confidential and used for applicant demographics only. IF YOU HAVE ANY QUESTIONS REGARDING YOUR APPLICATION PLEASE CALL (951) 571-6166 17

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