Health Sciences Program Application

Mailing Address
Mailing Address
Birthdate
Birthdate
For which Program(s) are you applying?
For which Program(s) are you applying?
Most Health Science programs require a minimum ACT score. Please refer to the program's posted minimum requirements, found on the program's website.

If you have taken or plan to take the ACT, please be sure you have selected MDCC to recieve your scores. 

Have you taken the ACT?
Most Health Science programs require a minimum ACT score. Please refer to the program's posted minimum requirements, found on the program's website.

If you have taken or plan to take the ACT, please be sure you have selected MDCC to recieve your scores. 

Have you taken the ACT?
Most Health Science programs require an entrance test. Please refer to the program's posted minimum requirements, found on the program's website.

Please be sure you have selected TEAS test score sent to MDCC Health Sciences.

Have you taken the TEAS Test?
Most Health Science programs require an entrance test. Please refer to the program's posted minimum requirements, found on the program's website.

Please be sure you have selected TEAS test score sent to MDCC Health Sciences.

Have you taken the TEAS Test?
Choose the course(s) that you have completed within the last 5 years & received a C or better grade.
Choose the course(s) that you have completed within the last 5 years & received a C or better grade.
Have you ever attended college?
Have you ever attended college?
Have you ever attended a Health Science Program?
Have you ever attended a Health Science Program?
Did you complete this program?
Did you complete this program?
Please enter the date you completed the program. If you did not complete, leave the date blank.
Please enter the date you completed the program. If you did not complete, leave the date blank.
Do you plan to apply to another Health Science Program this year?
Do you plan to apply to another Health Science Program this year?
Have you ever been employed in a health care setting?
Have you ever been employed in a health care setting?
When did you start in this position? If you have not worked in a health care setting, leave the date blank.
When did you start in this position? If you have not worked in a health care setting, leave the date blank.
Do you still hold this position? If you have not worked in a health care setting, select No.
Do you still hold this position? If you have not worked in a health care setting, select No.
When did your employment end in this position? If you have not worked in a health care setting, leave the date blank.
When did your employment end in this position? If you have not worked in a health care setting, leave the date blank.
Do you currently hold a license or certification in a Health Care Field? (Current unencumbered Mississippi LPN License REQUIRED for Accelerated Track to ADN)
Do you currently hold a license or certification in a Health Care Field? (Current unencumbered Mississippi LPN License REQUIRED for Accelerated Track to ADN)
What type of licensure or certificate do you have?
What type of licensure or certificate do you have?
What date was your last licensure or certificate obtained? If you do not have a certification or license, leave the date blank.
What date was your last licensure or certificate obtained? If you do not have a certification or license, leave the date blank.
Do you understand that if accepted into a Health Science Program you will be required to be fingerprinted by our office for a Healthcare Criminal History background check? **See our Background Information Policy found at www.msdelta.edu**
Do you understand that if accepted into a Health Science Program you will be required to be fingerprinted by our office for a Healthcare Criminal History background check? **See our Background Information Policy found at www.msdelta.edu**
Have you ever been denied licensure/certification, had disciplinary action or is action pending against you by the licensure/certification board or any other regulatory agency or certification organization in any state or jurisdiction?
Have you ever been denied licensure/certification, had disciplinary action or is action pending against you by the licensure/certification board or any other regulatory agency or certification organization in any state or jurisdiction?
Have you ever been convicted of, plead guilty or plead nolo contendere to any charge(s), or are charges pending against you for a felony or misdemeanor, other than minor traffic violations, in any state or jurisdiction?
Have you ever been convicted of, plead guilty or plead nolo contendere to any charge(s), or are charges pending against you for a felony or misdemeanor, other than minor traffic violations, in any state or jurisdiction?
Have you ever been convicted of a felony, or plead guilty or plead nolo contendere to a felony of possession or sale of drugs, murder, manslaughter, armed robbery, rape, sexual battery, sex offense, listed in Section 45-33-23(h), child abuse, arson, grand larceny, burglary, gratification of lust or aggravated assault, or felonious abuse and/or battery of a vulnerable adult? Health Care Institutions may, at their discretion, refuse clinical experience. Being unable to attend clinical at some clinical facilities may result in a student failure to progress in their program of study. Please request a personal appointment if you may have a disqualifying offense.
Have you ever been convicted of a felony, or plead guilty or plead nolo contendere to a felony of possession or sale of drugs, murder, manslaughter, armed robbery, rape, sexual battery, sex offense, listed in Section 45-33-23(h), child abuse, arson, grand larceny, burglary, gratification of lust or aggravated assault, or felonious abuse and/or battery of a vulnerable adult? Health Care Institutions may, at their discretion, refuse clinical experience. Being unable to attend clinical at some clinical facilities may result in a student failure to progress in their program of study. Please request a personal appointment if you may have a disqualifying offense.
Do you understand that if accepted into a Health Science Program drug testing is required for admission, readmission, and/or progression in MDCC Health Science programs? All testing or screening will be done by certified laboratories who maintain normal chain of custody requirements. Substance screen results must meet all MDCC affiliated clinical agency requirements, and this issue may not be altered or changed by this policy. If a clinical requirement of a provider conflicts with this policy, the clinical agreement shall control. **See our Substance Use Policy found at www.msdelta.edu**

 
Do you understand that if accepted into a Health Science Program drug testing is required for admission, readmission, and/or progression in MDCC Health Science programs? All testing or screening will be done by certified laboratories who maintain normal chain of custody requirements. Substance screen results must meet all MDCC affiliated clinical agency requirements, and this issue may not be altered or changed by this policy. If a clinical requirement of a provider conflicts with this policy, the clinical agreement shall control. **See our Substance Use Policy found at www.msdelta.edu**

 
Do you understand the Health Science Program specific functional skills/abilities that are considered essential for the practice in that Health Care Field? These include: critical thinking, interpersonal skills, verbal and written communication skills, physical mobility, fine motor skills, hearing, vision, and reading competencies. **See our Core Standards at each program website at msdelta.edu.

 
Do you understand the Health Science Program specific functional skills/abilities that are considered essential for the practice in that Health Care Field? These include: critical thinking, interpersonal skills, verbal and written communication skills, physical mobility, fine motor skills, hearing, vision, and reading competencies. **See our Core Standards at each program website at msdelta.edu.

 
According to Mississippi State Law, an individual may not be eligible for employment in a health care agency if the person has ever been convicted of a felony , or plea guilty to , or plea nolo contendere to a felony of possession or sale of drugs, murder, manslaughter, armed robbery, rape, sexual battery, sex offense listed in Section 45-33-23 (h), child abuse, arson, grand larceny, burglary, gratification of lust or aggravated assault, of felonious abuse and/or battery of a vulnerable adult.
 
According to Mississippi State Law, an individual may not be eligible for employment in a health care agency if the person has ever been convicted of a felony , or plea guilty to , or plea nolo contendere to a felony of possession or sale of drugs, murder, manslaughter, armed robbery, rape, sexual battery, sex offense listed in Section 45-33-23 (h), child abuse, arson, grand larceny, burglary, gratification of lust or aggravated assault, of felonious abuse and/or battery of a vulnerable adult.
 
Any statements made on this application which are false and known to be false by the applicant at the time of making such statements, shall be deemed fraudulent and subjects the applicant to disciplinary proceedings.
 
Any statements made on this application which are false and known to be false by the applicant at the time of making such statements, shall be deemed fraudulent and subjects the applicant to disciplinary proceedings.
 
Professional licensure requirements are found by choosing your selected Health Science Program at www.msdelta.edu.
 
Professional licensure requirements are found by choosing your selected Health Science Program at www.msdelta.edu.
 
Do you require special accommodations to the meet the performance standards? (Completion is optional)
Do you require special accommodations to the meet the performance standards? (Completion is optional)

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