Program is pending accreditation candidacy by the Accreditation … · 2019-04-25 · Program is pending accreditation candidacy by the Accreditation Commission for Education in Nursing

Program is pending accreditation candidacy by the Accreditation Commission for Education in Nursing (ACEN)

Welcome to Dixie Technical College. Please complete the items listed below and submit your application to the Student Services Department at Dixie Tech. Incomplete Applications will not be accepted.

APPLY TO DIXIE TECHNICAL COLLEGE ❏ Dixie Technical College General Application and $40 Application Fee • Complete online: go to dixietech.edu and click “Apply Now”

APPLY TO THE PRACTICAL NURSING PROGRAM

❏ Copy of High School Diploma or GED ❏ HESI A2 Entrance Exam

The HESI A2 exam must be passed with a 75% or better in each section. Please allow a minimum of 4-6 weeks before the application deadline for taking this test. Contact Dixie Technical College Testing Center at (435)674-8427 for an appointment. The test score is valid for 1 year. Include a copy of the letter and test score sheet with your application.

❏ Practical Nursing Application ❏ Mental and Physical Job Requirements – See attached information sheet ❏ Professional Goal Statement – See attached information sheet ❏ 3 Professional References See attached information sheet ❏ Official Transcripts verifying required prerequisite courses (minimum grade of C or higher): - BIOL 2320/2325 Human Anatomy and Lab - BIOL 2420/2425 Human Physiology and Lab ❏ Proof of Required Immunizations – See attached information sheet ❏ Proof of current CNA certification ❏ Proof of current American Heart Association CPR certification ❏ Drug Screen (12-Panel) Call Student Services at 435-674-8400 ❏ Background Check Call Student Services at 435-674-8400 ❏ Adult or Minor Consent, Release and Acknowledgement ❏ Application Review

Application Timeline:

May 31, 2019 Applications due by close of business day June 17, 2019 Scheduled program start date

Upon program approval, applications may be accepted after the due date if space is remaining.

DIXIE TECH NURSING ASSISTANTCOURSE HOURS TUITION FEES BOOKSNRSG 1010 Foundations of Medical Surgical Nursing 126 $283.50 $392.66 $265.00 XNRSG 1015 Nursing Care of Diverse Populations 48 $108.00 $314.66 XNRSG 1020 Pharmacological Nursing Care I 36 $81.00 $302.66 XNRSG 1010L Med Surg, Diverse Pop, Pharm I, Lab/Clinical 240 $540.00 $240.00 XNRSG 1025 Pharmacological Nursing Care II 36 $81.00 $302.66 XNRSG 1030 Nursing Across the Lifespan 90 $202.50 $356.66 XNRSG 1030L Pharm II, Lifespan Lab/Clinical 294 $661.50 $294.00 XNRSG 1040 Professional Development 30 $67.50 $296.70 X INSTRUCTORS

Jan Call | 435-674-8470 | [email protected] Graduation Fee $40.00 X Mekael Holt | 435-674-8463 | [email protected]

CLASSROOM HOURSMon - Thur 9:00 to 4:00 (until clinicals start, approx. 7 wks)Mon & Wed 9:00 to 4:00 + 12 Clinical Hours Per Week

TUITION $2.25 Per Seat Hour

INITIAL FEE/ADDITIONAL FEE ESTIMATE $40.00 Dixie Tech Application Fee $60.00 HESI A2 Entrance Exam $25.00 Urine Drug Screen$53.00 Fingerprints/Background Check$45.00 Scrubs$55.00 Stethoscope and Blood Pressure Cuff$200.00 NCLEX National Exam

ENROLLMENT DATES6/17/2019 6/15/2020

High school students are required to pay books and fees. THIS PROGRAM IS ELIGIBLE FOR FEDERAL FINANCIAL AID TOTAL HOURS 900 Tuition & Fees must be paid before registering for class unless a

payment plan or other funding options have been approved and signed. Information is subject to change without notice.

Tuition $2,025.00Program Fees $2,540.00Textbooks $265.00APPROXIMATE COST $4,830.00

Important Information About Your HESI Admission Assessment Exam

16-NHPjp-0239 TM/RZ 4/16

THIS IS WHAT YOU’LL BE TESTING ON:

HERE ARE THE EXAM DETAILS:

Make sure you’re prepared for the HESI Admission

Assessment Exam!

ISBN: 978-0-323-35378-6

PRACTICAL NURSING PROGRAM APPLICATION FOR PROGRAM ACCEPTANCE Dixie Technical College’s Practical Nursing Program is a candidate for accreditation by the Accreditation Commission for Education in Nursing (ACEN) (Please print legibly in black or blue ink) Full Name: __________________________________________________________________________________ First Middle (Maiden) Last Home Address: __________________________________________________________________________________

City, State, Zip Mailing Address (if different from above): __________________________________________________________________________________ Email address: _______________________________________Date of Birth: __________________ Cell Phone:______________________________ Home Phone: _____________________________ Emergency Contact Name: _______________________________ Phone: __________________ Education List high schools and/or colleges attended (beginning with high school). Degrees must be from a regionally accredited college or university to be considered for points.

Name of School Dates of Attendance Degree?

From To Yes No

List any honors and special awards you have received throughout your education: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Health Care Training Certified Nursing Assistant (CNA) Yes ____ No ____ Date of Expiration ______________ Medical Assistant (MA) Yes ____ No ____ Date of Expiration ______________ If “Yes”, please include a copy of current certification in your application. Health Care Work and / or Health Care Volunteer Experience List most recent work or volunteer experience first. If none, indicate by N/A. May attach separate sheet if necessary. Agency_______________________________________________ Phone ____________________ Address ________________________________________________________________________ Position_________________________________ Supervisor ______________________________ Job Description___________________________________________________________________ Total months and or years employed or volunteered, dates from when to when Dates from when to when ____________________________ years _______months_______ Circle One: Full-Time (32+ hrs/wk) Part-time (2-31 hrs/wk) Agency_______________________________________________ Phone ____________________ Address ________________________________________________________________________ Position_________________________________ Supervisor ______________________________ Job Description___________________________________________________________________ Total months and or years employed or volunteered, dates from when to when Dates from when to when ____________________________ years _______months_______

Circle One: Full-Time (32+ hrs/wk) Part-time (2-31 hrs/wk) Agency_______________________________________________ Phone ____________________ Address ________________________________________________________________________ Position_________________________________ Supervisor ______________________________ Job Description___________________________________________________________________ Total months and or years employed or volunteered, dates from when to when Dates from when to when ____________________________ years _______months_______ Circle One: Full-Time (32+ hrs/wk) Part-time (2-31 hrs/wk) Agency_______________________________________________ Phone ____________________ Address ________________________________________________________________________ Position_________________________________ Supervisor ______________________________ Job Description___________________________________________________________________ Total months and or years employed or volunteered, dates from when to when Dates from when to when ____________________________ years _______months_______ Circle One: Full-Time (32+ hrs/wk) Part-time (2-31 hrs/wk)

References List the names of the three professional people who will be completing your reference evaluation forms. These must be people who are now or who have been your employer, supervisor, former instructor, or community leader. They must have known you for at least six months and cannot be related to you. You must have three reference forms returned in order to potentially receive the maximum three points. Two reference forms are required for application consideration but will not qualify for all three points. Name ___________________________________________ Address ________________________________________________________________________ Institution__________________________________________ Position ______________________

Name ___________________________________________ Address ________________________________________________________________________ Institution__________________________________________ Position ______________________

Name ___________________________________________ Address ________________________________________________________________________ Institution__________________________________________ Position ______________________

Important!!! Be Sure to Read the Following: In order to be a licensed nurse in the State of Utah, the applicant must be in conformity with the Utah Nurse Practice Act. Applicants who have been convicted of a felony; treated for mental illness or substance abuse; have been involved as the abuser in any incident of verbal, physical, mental, or sexual abuse; or may pose a threat to themselves, patients, clients, or to the public health, safety, or welfare because of any circumstances or conditions, should discuss their eligibility status with the Utah State Board of Nursing at the following telephone numbers: (801) 530-6628; (866) ASK-DOPL (toll free in Utah); (866) 275-3675 Acceptance and completion of the Dixie Tech Practical Nursing Program does not ensure eligibility to sit for the Nursing licensure exam. The Utah Board of Nursing makes the final decision on issue of license to practice in the State of Utah. If you have a record of convicted criminal actions it may affect your eligibility for admission to the Dixie Tech Practical Nursing Program. Admission to the program is contingent upon submission of a satisfactory background check and random drug testing. If a background check reveals a history of convicted criminal actions you may be expelled from the program.

Prerequisite Unofficial Grade Worksheet Applicant Name ______________________________________________________ Please fill out the information below concerning your prerequisite and preadmission courses. This will assist us in making sure all of your courses are accounted for. Be sure to transfer the exact grade, with a plus or minus as applicable. Please be aware that all grades will be verified using official transcripts. All prerequisite and preadmission courses must be completed with a grade of “C” or better. Grades of “C-” or below are unacceptable. The prerequisite and preadmission cumulative GPA must be 3.0 or higher. Prerequisite and preadmission courses may not be taken more than two times during the five years prior to application. Prerequisite courses must be taken from a regionally-accredited college or university. Pass/Fail and Credit/No Credit scores are not accepted. AP credit is granted if the score is 4 or 5 and has been taken in the last 5 years. Courses must be taken within 4 years of starting the PN program if you are considering continuing on to an RN program.

Prerequisite Course Title School Year Semester Grade BIOL 2320 / 2325

BIOL 2420 / 2425

Recommended Course Title School Year Semester Grade BIOL 1200 Human Biology CHEM 1110/1115 Chemistry and Lab

MATH 1040 Introduction to Statistics

ENGL 1010 Introduction to Writing

FSHD 1020 Foundations of Nutrition

NURS 3900 or BIOL 4400 Pathophysiology

I understand that providing false or misinformation regarding the grades I received in any of the prerequisite or recommended courses may render my application incomplete. I also understand that official transcripts must be submitted to verify prerequisite course grades Signature_________________________________________________Date____________________

SATISFACTORY PROGRESS AND ATTENDANCE INFORMATION Students enrolled in the Practical Nursing Program are required to pass off competencies at 80% or higher for all coursework and/or lab assignments and maintain 80% cumulative satisfactory academic progress each semester. Absences are limited to two per semester. To progress satisfactorily through the Practical Nursing Program students must adhere to these program requirements. Students must be able to attend class and clinical sites which may include evening and weekend hours. Additionally, students must be able to have the time to study outside of class time. Failure to meet these standards will result in removal from the PN Program. By signing here I agree that I have read and I understand the satisfactory progress and attendance information on this page and agree to commit to prescribed hours and course of study. Signature_____________________________________________ Date______________________ PRIOR OR PENDING CRIMINAL OFFENSE INFORMATION Do you have a prior or pending criminal offense? Yes_____ No_____ (If yes, please attach information regarding the offense to this page prior to submitting application.) Please Note: In order to be licensed as a practical nurse in the state of Utah, you must be in conformity with the Utah Nurse Practice Act. If you have been convicted of a felony, treated for mental illness or substance abuse, you should discuss your eligibility with Utah State Board of Nursing. Acceptance and completion of the Dixie Tech PN Program does not assure eligibility to sit for the practical nursing licensure exam. The Utah State Board of Nursing makes the final decision as to whether a license will be issued to practice nursing in Utah. If you have any questions regarding this information about prior or pending criminal offenses please contact the Utah State Board of Nursing, 160 East 300 South, Salt lake City, UT 84111 Telephone number (801) 530-6628. APPLICATION STATEMENT I do herby certify the statements in this application are true and complete to the best of my knowledge. I understand that falsifying information on this application may be grounds for dismissal. Signature______________________________________________ Date_______________________

Processing Applications

1. Once the application period is closed, applicants will be evaluated using a point system based on prior degrees, experience (work/volunteer), and reference letters.

2. A maximum of 12 students will be conditionally accepted into the program. All other qualified applicants will be placed in a rank-order on an alternate waiting list. If you are an alternate, you may be notified of an available seat as late as the beginning of the first week of class.

3. Full admittance into the PN Program is contingent upon verification of a negative 10-panel drug screen and evidence of immunization requirements.

4. Applicants not accepted and wishing to re-apply may do so in the future using the most current PN Program application. Admission to the PN Program is not guaranteed.

Scoring System Used – Practical Nursing Program Criterion Points Awarded

1. Prior Degrees _____/2 Associate Degree +1 Bachelor’s Degree (BA or BS) or > +2 Points only awarded for highest degree earned

2. Health Care Work Experience _____/4

6 months +1 7-12 months +2 13-23 months +3 24 months or more +4

3. Volunteer Experience _____/3

7 months +1 7-12 months +2 13 months or more +3

4. Reference Letters _____/6

Response Do not support the student +0 Support with reservation +1 Strongly support +2

5. Professional Goal Statement _____/6

6. HESI Scores _____/29

Total Points _____/50 By signing here, I agree that I have read and understand the information on this page. Signature____________________________________________ Date_________________________

Dixie Technical College 610 S. Tech Ridge Drive, St. George, UT 84770 435-674-8400

Dixie Technical College (Dixie Tech) values diversity in the students who wish to enter the nursing profession. We want you to succeed so you must be aware that there are some functional requirements, environmental factors and even some psycho-social demands that will be required of you in order to achieve this success. Requirement and factors are but are not limited to:

1. Must be able to independently push, pull, and lift a medically-fragile adult when positioning or transferring.

2. Must have the ability to palpate body structures and be able to differentiate and report subtle variations in temperature, consistency, texture, and structure.

3. Must be able to hear, identify, and distinguish subtle variations in body sounds (i.e. lung, heart and bowel).

4. Must be able to read, understand, and apply printed material which may include instructions printed on medical devices, equipment, and supplies.

5. Must be able to visually distinguish subtle diagnostic variations in physical appearance of persons served. An example would be "pale color."

6. Must be able to distinguish subtle olfactory changes in physical characteristics of persons served.

7. Must be able to walk and stand for extended periods of time. 8. Must possess the ability to simultaneously and rapidly coordinate mental and muscular

coordination when performing nursing tasks. 9. Must be able to effectively communicate in English, in both written and verbal format. 10. Protracted or irregular hours of work, varying 2-12 hours including days and evenings. 11. Ability to work in confined and/or crowded spaces. 12. Ability to work independently as well as with coordinated teams. 13. Potential exposure to harmful substances and/or hazards. 14. Ability to maintain emotional stability during periods of high stress. 15. Ability to work in an emotionally-charged or stressful environment.

CPR Certification CPR certification is required to practice in all healthcare facilities. Every student must be currently certified in Basic Life Support (BLS) for adults and children from the American Heart Association before participating in clinical experiences. Two-year certification is acceptable and preferred. A copy of the Certification card must be provided at time of registration for Dixie Tech Practical Nursing Program. BLS certification must not expire prior to the completion of the program. It is the student's responsibility to obtain/maintain his/her CPR certification, and the student may not attend clinical if it expires during the semester. I have read and understand the “Mental & Physical Job Requirements”. I do not have any mental or physical limitations that would prevent me from carrying out these requirements to the best of my knowledge. Student Signature: _________________________________________ Date __________________


Professional Goal Statement Applicant Name _____________________________________________________ Using the lines below and on the next page, write a statement of your professional goals. Scoring is based on the following criteria:

• The statement must be handwritten; typed statements will not be accepted. • The statement must be a minimum of 150 words and a maximum of 200 words. Count

carefully!!! • The statement will be graded on legibility, spelling, punctuation, grammar, and sentence

structure.

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PROFESSIONAL REFERENCE EVALUATION Instructions to the applicant: This section is to be filled out by the applicant to the Dixie Technical College’s Practical Nursing Program, in blue ink, prior to providing to the person completing the evaluation. Printed name of applicant requesting reference: _______________________________________ Signature___________________________________________ Date_______________________

Instructions to the evaluator: Please complete the remainder of this document. NOTE: This form will become part of the applicant’s Practical Nursing Program Student File at the Dixie Technical College. Students have the right to review their Student File, upon request, as guaranteed by the Family Educational Rights and Privacy Act (FERPA) of 1974 and its amendments. The applicant, listed above, respectfully requests that you complete this reference evaluation as part of their application process into the College’s Practical Nursing Program. Program faculty and staff are interested in your candid appraisal of the applicant’s abilities and thank you in advance for completing this three page professional reference evaluation in a timely manner. Evaluator’s printed name: _________________________________________________________ Signature: __________________________________________Date: ______________________ Title: ___________________________________Institution: _____________________________ Length of time you have known this applicant: _________________________________________ Capacity in which you have known applicant: (please circle one): Supervisor Teacher Employer RN Other: (Explain) __________________________ __________________________________________________________________________________ Instructions: The following questions or statements identify a variety of traits, skills, attitudes, etc. Please indicate the degree to which each quality is characteristic of the candidate you are rating by reading the statement carefully, reading the points on the scale, and circling the number of your choice on the scale. Please rate each statement independently and avoid a tendency to rate on general impressions. One characteristic might influence the rating of all characteristics. Specific comments in each category are encouraged.


Problem Solving: Ability to identify and solve problems Circle one: 1 2 3 4 5 Unable to Assess (Poor) (Satisfactory) (Average) (Good) (Excellent) Comment: ___________________________________________________________________

Attitude: Outlook projected towards life, school, job, etc. Circle one: 1 2 3 4 5 Unable to Assess (Poor) (Satisfactory) (Average) (Good) (Excellent) Comment: ___________________________________________________________________

Stress / Anxiety Response: Deals with stressful, anxiety producing situations Circle one: 1 2 3 4 5 Unable to Assess (Poor) (Satisfactory) (Average) (Good) (Excellent) Comment: ___________________________________________________________________

Motivation / Accountability: Extent to which individual applies self and is accountable Circle one: 1 2 3 4 5 Unable to Assess (Poor) (Satisfactory) (Average) (Good) (Excellent) Comment: ___________________________________________________________________

Appearance: Extent to which standards of appearance are met Circle one: 1 2 3 4 5 Unable to Assess (Poor) (Satisfactory) (Average) (Good) (Excellent) Comment: ___________________________________________________________________

Punctuality / Absenteeism Circle one: 1 2 3 4 5 Unable to Assess (Poor) (Satisfactory) (Average) (Good) (Excellent)

Comment: ___________________________________________________________________


Communication Skills: Ability to communicate with peers, coworkers, teachers, etc. Circle one: 1 2 3 4 5 Unable to Assess (Poor) (Satisfactory) (Average) (Good) (Excellent) Comment: ___________________________________________________________________

Integrity: Extend to which the candidate displays a moral and ethical code Circle one: 1 2 3 4 5 Unable to Assess (Poor) (Satisfactory) (Average) (Good) (Excellent) Comment: ___________________________________________________________________

Interpersonal Relationships: Ability to cooperate and get along with peers, coworkers, teachers, employees, etc. Circle one: 1 2 3 4 5 Unable to Assess (Poor) (Satisfactory) (Average) (Good) (Excellent) Comment: ___________________________________________________________________

In summary, please indicate the degree to which you support this applicant for study in Nursing: _____ I strongly support this applicant. _____ I support with reservation. Please indicate your concerns in the comments section below. _____ I do not support this applicant. Please indicate your concerns in the comments section

below. Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Additional comments may be placed on a separate page. Place in envelop, seal the envelope, Sign the envelope over the seal, return to applicant. (Envelopes will not be accepted unsigned)











Comment: ___________________________________________________________________

















Comment: ___________________________________________________________________







Contact: Call for appointment – Dixie Tech Student Services at 435-674-8400 Cost: Urine drug screen - $25 payable to Dixie Tech Location: Dixie Tech Student Services Security Office, Bldg. 3A-3 Required: Photo ID Receipt for payment of $25 Minors: If you are a minor, your parent/guardian must accompany you or be available

for contact at the time of the appointment. Results: Results will be available the same day. If student completes the drug screening at another facility, results must be

returned in a sealed envelope to Dixie Tech. Drugs Tested Amphetamines, Barbiturates, Buprenorphine, Benzodiazepines, Cocaine, For: Synthetic Marijuana, Methamphetamine, Ecstasy/Molly, Morphine,

Methadone, Oxycodone, Marijuana

If you take medication which will test positive for any of the above, bring your prescription with you at the time of testing

Fingerprints/ Background Check Contact: Dixie Tech Student Services 435-674-8400 Cost: $20 Fingerprint fee (payable to Dixie Tech)

$15 State Background Check (payable by credit card, check, money order or cashier’s check to the Utah Bureau of Criminal Identification)

$18 Federal Background Check (payable by credit card, certified check or money order to the FBI CJIS Division)

Instructions Step 1: Fill out both the State and Federal Background forms included in this application

packet. Step 2: After completing the forms, Call Dixie Tech Student Services to schedule an

appointment for fingerprinting. Step 3: Bring completed forms, payment, and a valid ID that includes photo, signature,

and date of birth (ex: driver’s license) to your fingerprinting appointment. Step 4: After having your fingerprints taken, stamped envelopes will be available for

sending the information to the appropriate State and Federal Agencies. The signed Third Party Release Form and FBI form will allow the state and federal results to be sent directly to Dixie Technical College.

$15.00 APPLICATION FEE - DO NOT SEND CASH IN THE MAIL METHOD OF PAYMENT - FOR MAIL IN ONLY (Check appropriate box for payment)

Check, Money Order or Cashier’s Check (Payable to “Utah Bureau of Criminal Identification” in the amount of $15.00)

Credit Card (cannot use foreign credit cards) must be Visa Master Card AMEX Discover Fill info below to pay by credit card.

PRINT NAME (As it appears on the card): _____________________________________________________________________________

TOTAL AMOUNT OF PURCHASE: $ CREDIT CARD BILLING ZIP CODE: ____________

CARDHOLDER SIGNATURE: ______________________________________________ DATE: _______________________

Credit Card Number 15 digit AMEX or 16 digit Visa, Mastercard or Discover * 3 or 4 digit control # Expiration Date

R form 98-1-03, Rev 12/2017

APPLICATION FOR CRIMINAL HISTORY RECORD

Utah Department of Public Safety • Bureau of Criminal Identification

3888 West 5400 South, Taylorsville, Utah 84129 - Telephone: (801)965-4445

WHEN FILLING OUT THIS APPLICATION TYPE OR PRINT IN BLACK INK. Your application will not be processed unless all sections of this

form are filled out completely. You will need a valid form of government issued picture ID and $15.00 fee.

NAME: DATE OF BIRTH________________ (Last Name) (First Name) (Middle Name) PREVIOUSLY USED NAME(S) (Maiden, etc.): ______________________________________________________________________

MAILING ADDRESS: ___________________________________________________________________________________________ (Street/Box number) (City) (State) (Zip)

PHYSICAL ADDRESS: __________________________________________________________________________________________ (Street) (City) (State) (Zip)

HOME PHONE NUMBER: DAYTIME PHONE NUMBER: __________________________________

SOCIAL SECURITY: DRIVER LICENSE # AND STATE: __________________________________

PHYSICAL DESCRIPTION: HGT/ WGT/ EYE COLOR/ SEX/ RACE/_____________

I hereby declare that I am the person listed above and am entitled to my criminal record as provided by Utah Code Ann. § 53-10-108(9)(a).

The information contained in this written statement is true and correct to the best of my knowledge and I understand that any false statements

I make that I do not believe to be true may subject me to criminal punishment as a class B misdemeanor pursuant to Utah Code Ann. §76-8-504.

Signature of applicant: Date: ____________________________

FINGERPRINT INSTRUCTIONS: (OFFICIAL TAKING PRINTS) Confirm identity of applicant with identification that shows photo,

signature and date of birth. Confirm ID with the information above, then list the type of government issued ID used and the ID number in the space

provided below. Fingerprint the four fingers of the applicant’s right hand simultaneously in the box located in the lower right portion of this form.

This Area must be completed by OFFICIAL TAKING PRINTS

Type of identification used:

(Utah Driving Privilege Cards are not valid ID and will not be accepted)

Identification number:

Name on ID:

Fingerprints taken by: (PRINT NAME)

Agency Name:

Badge # Date Printed:

(If applicable)

FINGERPRINTS

BUREAU USE ONLY AFIS Confirmation

SID# R&F

THIRD PARTY RELEASE FORM Utah Department of Public Safety • Bureau of Criminal Identification

3888 West 5400 South, Taylorsville, Utah 84129

WHEN FILLING OUT THIS FORM, TYPE OR PRINT IN BLACK INK. If you wish to have your criminal history record or certificate of

eligibility sent to an individual other than yourself, you must indicate the name of the person or agency to whom you would like the document sent and

the mailing address.

NAME:

(Name of Person to Receive Report)

AGENCY: _____________________________________________________________________ (if applicable)

MAILING ADDRESS:

(Street/Box number) (City) (State) (Zip)

I request that the criminal history record or certificate of eligibility for which I applied be released to the individual or agency indicated

above at the listed address. I hereby release the Bureau of Criminal Identification from any liability resulting from such release.

Name of applicant (Print):

Signature of applicant: Date: _______________________

Rick Hafen

Dixie Technical College

610 South Tech Ridge Drive St George Utah 84770

I-783 (Rev. 04-02-2014) OMB-1110-0052

PRIVACY ACT STATEMENT The FBI’s acquisition, retention, and sharing of information submitted on this form is generally authorized under 28 USC 534 and 28 CFR 16.30-16.34. The purpose for requesting this information from you is to provide theFBI with a minimum of identifying data to permit an accurate and timely search of identity history identification records. Providing this information (including your Social Security Account Number) is voluntary; however,failure to provide the information may affect the completion of your request. The information reported on this form may be disclosed pursuant to your consent, and may also be disclosed by the FBI without your consent pursuantto the Privacy Act of 1974 and all applicable routine uses. Under the Paperwork Reduction Act, you are not required to complete this form unless it contains a valid OMB control number. The form takes approximately 3 minutesto complete.

Applicant Information * Denotes Required Fields *Last Name *First NameMiddle Name 1 Middle Name 2

*Date of Birth: *Place of Birth: U.S. Citizen or Legal Permanent Resident: Yes No

*Country of Citizenship: Country of Residence: Prisoner Number (if applicable):

*Last Four Digits of Social Security Number:

*Height: *Weight:

*Hair (please check appropriate box):

Bald Black Blonde/Strawberry Blue Brown Gray Green Orange Pink Purple Red/Auburn Sandy Unknown White

*Eyes (please check appropriate box):

Black Blue Brown Gray Green Hazel Maroon Multicolored Pink Unknown

Applicant Home Address *Address

*City *State*Postal (Zip) Code *CountryPhone Number E-Mail

Mail Results to Address C/O ATTN Address

City State Postal (Zip) Code Country Phone Number (if different from above)

Payment Enclosed: (please check appropriate box) CERTIFIED CHECK MONEY ORDER CREDIT CARD FORM

Reason for Request: Personal review Challenge information on your record Adoption of a child in the U.S. International adoption Live, work, or travel in a foreign country Other

* APPLICANT SIGNATURE DATE

Mail the signed applicant information form, fingerprint card, and payment of $18 U.S. dollars to the following address:

FBI CJIS Division – Summary Request 1000 Custer Hollow Road

Clarksburg, West Virginia 26306

You may request a copy of your own Identity History Summary to review it or obtain a change, correction, or an update to the summary.

X

DIXIE TECHNICAL COLLEGE RICK HAFEN

610 SOUTH TECH RIDGE DRIVEST GEORGE UTAH

84770 USA435-674-8400

1-786 (03-02-2017) OMB-1110-0070

NO CHARGE BACKS OR REFUNDS ALL SALES FINAL

CREDIT CARD PAYMENT FORM General Information: Complete the fields below and sign the authorization. (*Denotes Required Fields) The Federal Bureau of Investigation (FBI) cannot process credit card payments without an authorized signature. Failure to provide the requested information may result in the FBI and your financial institution not accepting the payment. (Refer to reverse side of form for applicable Privacy Act and Paperwork Reduction Act statements as related to this form.)

Applicant Name * Name (AS IT APPEARS ON CREDIT CARD) Company Name (if applicable) * Billing Address Billing Address 2 * City * State/Province * Postal (zip) Code * Country *Credit Card #: *Expiration Date (MM/YYYY) * Security Code: *Total Amount To Be Billed To Credit Card $ (____x $18 US Dollars Per Request) *Card Holder Signature


Provide proof of the following immunizations: 1. Tetanus and Diphtheria (TD) within 7 – 10 years.

2. Two (2) MMR vaccinations or a positive antibody titer to show immunity.

3. Three (3) Hepatitis B vaccinations. Any student who works directly with patients or body fluid specimens is required to have completed a 3-dose series of Hepatitis B Vaccine.

4. Influenza vaccination. Must be received annually.

5. Verification of TB testing within the past year. This must be done by an intradermal PPD test. If PPD test is positive, students must show that they have had an adequate work-up for tuberculosis and are currently NOT communicable. (chest x-ray report, physician or health department note.)

6. Varicella (Chicken Pox): 2 vaccinations, written verification of the disease by a Healthcare Provider or Laboratory blood titer test.


Name of Student ______________________________ Phone # ____________________________________ Date of Birth __________________________________ Dixie Tech Student ID# ________________________ PHOTOGRAPHY/VIDEO CONSENT Occasionally, Dixie Tech may photograph/video students for use in catalogues and brochures and on its informational website. ❏ I hereby consent to the use of my name, photo, video and audio for the purposes of advertising and

promoting Dixie Tech programs. I waive the right to approve any such publicity or promotional materials and understand that I will receive no compensation for my consent.

Signature __________________________________________________ Date ___________________ ❏ I do not want photographs/video of myself to be used for informational or promotional materials. Signature __________________________________________________ Date ___________________ MEDICAL TREATMENT/RELEASE OF LIABILITY I hereby agree as follows: 1. I understand there are potential risks of injury involved with participating in organized educational activities.

I agree to assume all risk and responsibilities surrounding my participation in the College program and use of College facilities. I understand that I will be required to adhere to all safety policies and procedures of my enrolled program.

2. In the event that I am injured or ill and become medically unresponsive while participating in a College

program and emergency medical treatment is necessary, I hereby consent to be transferred to a hospital emergency room to be seen by a physician. I hereby accept full responsibility for the payment of all costs incurred for such emergency treatment.

3. I hereby acknowledge and agree that Dixie Tech and its employees and agents are not responsible for

the kind or quality of emergency medical treatment that I receive. 4. I, on behalf of myself and my heirs, legal representative and assigns, hereby release Dixie Tech, its officers,

directors, faculty, staff, volunteers, employees and agents (collectively “Dixie Tech”) from any present or future claim, cause of action, loss or liability for injury to person or property, related to participation in the Program and resulting from any incident or cause related to participation in the Program and resulting from any incident or cause, and to hold Dixie Tech harmless therefrom, including any claim for injury or loss caused to a third party.

This document shall be governed and construed under the laws of Utah. If any terms or provision of this release and hold harmless agreement shall be held illegal, unenforceable, or in conflict with any law governing this release and hold harmless agreement, the validity of the remaining portions shall not be affected thereby. I acknowledge I have read the foregoing document carefully and understand its contents and significance. Signature __________________________________________________ Date __________________________


Student Name (please print):

I.D. Number: Birthdate:

Program:

I hereby authorize Dixie Tech to release, discuss or share information contained in my College record with:

Family Member (Name & Relationship):

School Counselor:

Sponsoring Agency Case Worker:

Employer - Name: Phone Number:

Other:

I do not authorize Dixie Tech to release, discuss or share any information contained in my

College record in accordance with the Family Educational Rights and Privacy Act (FERPA). I understand that I can rescind this in writing at any time by completing a Release of Information Authorization form containing my signature and the date of authorization.

I understand that my student record will be held under strict confidentiality and will only be used for the stated purpose and reviewed by authorized Dixie Tech staff. I understand that I can rescind this authorization in writing at any time by notifying Student Services with a written notice containing my signature.

A photocopy or fax copy of this authorization shall be acceptable and considered as valid as an original signed document. I, as undersigned, acknowledge my understanding of this Release of Information Form. I further understand that this authorization is in effect until it is rescinded in writing.

Student Signature: Date:

Documents

Program is pending accreditation candidacy by the Accreditation … · 2019-04-25 · Program is pending accreditation candidacy by the Accreditation Commission for Education in Nursing