Medical Assisting Online Application

First Name:*

Middle Name:

Last Name:*

Mailing Address:*

City:*

State:*

Zip Code:*

Tech T#:

Date of Birth:*

Phone Number:*

Email:*

Please indicate if you are currently a student of:*

Arkansas Tech University

Arkansas Tech University-Ozark Campus

Another university

Have you previously attended another Medical Assisting Program?*

No

Yes

If you answered yes to the previous question, where?

I, the undersigned applicant to the Medical Assisting Program at Arkansas Tech University- Ozark Campus, understand that participation in a clinical experience is part of the Medical Assisting Program and that participation in a clinical experience includes working as a student at an affiliating agency. I understand that I will be responsible for all travel, meals, and lodging associated with clinical education. I further understand that affiliating agencies have the right to establish requirements for participation in clinical experience. I understand that I am responsible for providing copies of the documentation requested by the affiliated agency. I understand and agree that if I am rejected for participation in a clinical experience by an affiliating agency or if I refuse to submit to checks or tests that are required by an affiliating agency in order to participate in a clinical experience, I may be unable to complete my program of study and graduate from the Medical Assisting Program. I hereby release Arkansas Tech University-Ozark Campus, its employees, and all affiliating agencies from any liability with regard to my participation in a clinical experience and decisions made concerning my participation in a clinical experience.*

Yes, I understand

No

In accordance with the Americans with Disabilities Act (ADA) and other governmental regulations, technical standards that define the essential functions of medical assisting are listed in the documentation on the Medical Assisting webpage. I have read, ask for any clarification, and I fully understand all of the technical standards listed on the Medical Assisting webpage that are required to complete the Medical Assisting program at Arkansas Tech University-Ozark. *

Yes, I understand

No

Students are advised the Medical Assisting (MA) program is strenuous in nature. Students are therefore not allowed to take additional course work that is not directly related to their degree plan while in the MA Program. It is imperative all students who have financial aid funding contact the financial aid office to ensure understanding of aid and the funding restrictions associated with the MA program. I have read and understand how the policy, listed in the documentation on the Medical Assisting webpage, may affect my financial aid and my financial obligations to the college. *

Yes, I understand

No

As you prepare to take part in the medical assisting program, you need to know the occupational risks associated with the profession. I have read, asked for any clarification, and I fully understand the risks listed in the documentation on the Medical Assisting webpage that are associated with the Medical Assisting profession.*

Yes, I understand

No

I, the undersigned applicant to the Medical Assisting program at Arkansas Tech University Ozark Campus, understand that additional forms that can be found on the ATU-Ozark Medical Assisting webpage must be submitted to the Allied Health Administrative Assistant BEFORE the program application deadline in order for my application to be considered complete. I also understand that, if I complete the online application but do not submit these additional forms, my application will not be considered for admission to the program, as my application would not be fully submitted.*

Yes, I understand and will submit the additional documents

No