Meridian Institute of Surgical Assisting

How did you hear about Meridian? ___________________________________________

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REVISED:  May, 2009

MERIDIAN INSTITUTE OF SURGICAL ASSISTING

STUDENT APPLICATION

PO Box 758  Joelton TN  37080-0758

Toll-Free Number:  1-877/954-1500

Local:  615/746-6763;  Fax 615/499-4795

INSTRUCTIONS:  In order to be accepted, this Form must be typed or legibly printed.  If more space is needed than is provided on the application form, attach additional sheets and make reference to the questions being answered.  You are required to provide all information requested or you application may be delayed or suspended.  If you have any changes in your employment status, please include a copy of your resume.

It is the ongoing policy of our company to afford equal educational opportunity to qualified individuals regardless of their race, color, religion, sex, national origin, age, physical or mental handicap, veteran status, or because they are disabled veterans, and to conform to applicable laws and regulations.

Male ____

Female ____

____ Caucasian                            ____ African American                           

____ Hispanic                             ____ Other


                                                                                                                              

PRINTED NAME                            SIGNATURE                                    DATE

IDENTIFYING INFORMATION             Email Address:  ______________________

Last Name                               First Name                  Initial               Maiden Name

Birth date                    Birth place                               Social Security Number

                                                                                                            (     )                            

Home Address                                           City              State                    Zip           Home Telephone #

                                                                                                            (     )                            

Employed By                                                                                      Work Telephone #

Employers Address                                                                

EMPLOYMENT (Most current to previous)

Employer Name                                  Address                                               Telephone #

Position                                               Supervisor                   From (mmyy)   To (mmyy)

Employer Name                                  Address                                               Telephone #

Position                                               Supervisor                   From (mmyy)   To (mmyy)

Employer Name                                  Address                                               Telephone #

                                                            ________________-__                                              

Position                                               Supervisor                   From (mmyy)    To (mmyy)

EDUCATION (Chronological)

Institution Name                                             Address                                   Telephone #

Degree/Certificate                               Dates of Attendance                           Course

Institution Name                                             Address                                   Telephone#

Degree/Certificate                               Dates of Attendance                           Course

Institution Name                                             Address                                   Telephone #

Degree/Certificate                               Dates of Attendance                           Course

            Applicant hereby makes attestation that I received my high school diploma from __________________________________ (name of institution)

__________________________________

Applicant Signature

Date:  ____________________________

***All non R.N. and CST students must have completed a basic Anatomy and Physiology course prior to acceptance into Meridian’s SFA Online Program.  Please complete the following information:

            Name and Address of School:  _________________________________

                                                                _________________________________

                                                                _________________________________

            Name of Course:  ____________________________________________

            Year Obtained:     ____________________________________________

            I, __________________________, understand that it is my responsibility to obtain a copy of my transcripts from the above-referenced institution, and have them sent to Meridian Institute.  I further understand that this must be accomplished prior to my completion of the course.  If I fail to have my transcripts sent to Meridian Institute I understand I will not be able to graduate.

_____________________________

Date:  _______________________

ALL TRANSCRIPTS MUST BE CERTIFIED ORIGINAL COPIES (PHOTO COPIES WILL NOT BE ACCEPTED)

AFFILIATION AGREEMENT POLICY

            Each student, prior to beginning the clinical externship portion of the SFA Online Program, shall secure an affiliation (student training) agreement from the participating hospital.

            Meridian will provide a sample agreement to the hospital.  It is ultimately up to the student to insure follow-through with the hospital.

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STUDENT SIGNATURE

Date:  ______________________________

(By signing above, student acknowledges that clinicals will not be counted toward program completion unless an affiliation agreement is on file in Meridian’s office prior to beginning this phase.)

Effective Policy Date:  November 1, 2003

CPR CERTIFICATION

BLS/C    Expiration Date:                                       ACLS    Expiration Date:                              

MEMBERSHIP/AFFILIATIONS 

Please check which apply:

Association Surgical Technologists - Englewood, CO 80112 (303) 694-9130

Membership #:                                                                        Expiration Date:                                 

Association of Operating Room Nurses - Denver, CO 80231 (303) 755-6300

Membership #:                                                                        Expiration Date:                                 

COMMUNITY AFFILIATIONS

INSTUTUTIONAL APPOINTMENTS AND SURGICAL PRIVILEGES

Has your application for privileges at any Hospital ever been denied?    YES        NO

Have you ever resigned from or relinquished privileges at any Hospital or Healthcare institution?    YES    NO

Has your allied health professional privileges at any hospital been denied, been limited, suspended, revoked, not renewed or subjected to probationary or specified restrictions, or has any investigation been instituted or recommended by any hospital, medical staff committee or governing board?      YES       NO

IF THE ANSWER TO ANY OF THE ABOVE IS YES, PLEASE PROVIDE AN EXPLANATION OF THE DETAILS ON A SEPARATE SHEET AND ATTACH.

CERTIFICATION              

Please attach copy of Certificate(s)

Are you certified by any organization?    YES     NO   (if yes, please indicate below)

________________________________________________________________________

Certifying Organization                                                                      Certification #

Month and Year Certified                                                                  Expiration Date

Certifying Organization                                                                      Certification #

Month and Year Certified                                                                  Expiration Date

Certifying Organization                                                                      Certification #

Month and Year Certified                                                                  Expiration Date

Have you ever been denied certification or re-certification?      YES      NO

Has your certification ever been investigated, limited, suspended, placed on probation or stipulations added, or have you ever received a letter of admonition from a certifying board?    YES       NO

IF THE ANSWER TO EITHER OF THE ABOVE IS YES, PLEASE PROVIDE A FULL EXPLANATION OF THE DETAILS ON A SEPARATE SHEET AND ATTACH.

PLEASE ATTACH A COPY OF YOUR CURRENT LICENSE AND/OR ANY OTHER STATE LICENSES YOU HOLD.

Type of License                                  State                                                    License #

Month and Year Licensed                                                                  Expiration Date

CURRENT PROFESSIONAL LIABILITY COVERAGE

Professional Liability Insurance must be attained before beginning the clinical phase.  Please attach a copy of Certificate

            _____ Insured through employer                       _____Insured independently

Carrier Name                                                   Address

Policy #                                                                                   Expiration Date

Coverage Amount:                                                                                                                 

Are you applying for any functions not covered by your liability policy?  YES     NO

Has your present, or any past professional liability insurance carrier limited, excluded, or refused renewal of any specific function from your coverage?   YES     NO

If the answer to either of the above is yes, please list the functions, which have been excluded and provide an explanation on a separate sheet, including the name of the carrier, the date and specific information concerning any limitation.

Have any professional liability suits or claims ever been filed against you?    YES    NO

Are there any suits or claims currently pending?    YES     NO

Have any settlements or judgments been made by or against you in professional liability cases?    YES     NO

IF THE ANSWER TO EITHER OF THE ABOVE IS YES, PLEASE PROVIDE A FULL EXPLANATION OF THE DETAILS ON A SEPARATE SHEET AND ATTACH.

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

Carrier Name                                                   Address

Policy #                                                                                   Expiration Date

Carrier Name                                                   Address

Policy #                                                                                   Expiration Date

Have you ever been denied professional liability insurance coverage?    YES    NO

Has your professional liability insurance ever been cancelled, premiums surcharged or renewal refused?    YES      NO

IF THE ANSWER TO EITHER OF THE ABOVE IS YES, PLEASE STATE WHEN AND BY WHICH COMPANY BELOW:

Carrier Name                                                               Date of Policy Cancellation/Denial

Carrier Name                                                               Date of Policy Cancellation/Denial

Have any professional liability suites ever been filed against you?     YES     NO

Are there any suits currently pending from previous policies?     YES      NO

Have any settlements or judgments ever been made by or against you in professional liability cases?    YES       NO

IF THE ANSWER TO EITHER OF THE ABOVE IS YES, PLEASE LIST THE FUNCTIONS, WHICH HAVE BEEN EXCLUDED AND PROVIDE A FULL EXPLANATION ON A SEPARATE SHEET, INCLUDING THE NAME OF THE CARRIER, THE DATE AND SPECIFIC INFORMATION CONCERNING ANY LIMITATION.

ALLIED HEALTH PROFESSIONAL CATEGORIES

Please check the appropriate designation for which you are qualified by certification, licensure, or special education:

___Certified Surgical Technologist               ___Registered Nurse

___Surgical Technologist                              ___Licensed Practical Nurse

Do you wish to request any additional functions not specified in the scope of practice for your professional category listed above?        YES        NO

IF THE ANSWER TO THE ABOVE IS YES, PLEASE SPECIFY THE FUNCTION(S) AND PROVIDE DOCUMENTATION OF TRAINING AND EXPERIENCE.  GIVE A FULL EXPLANATION OF THE DETAILS ON A SEPARATE SHEET AND ATTACH.

Have you ever been publicly or privately warned, reprimanded or censured by a licensing body, a public or private certifying agent, a medical staff, a hospital or other health care facility?         YES          NO

Are there any claims or administrative agency or court cases pending against you?        YES        NO

Have any adverse administrative agency or court decisions ever been rendered against you, or have you ever been found guilty of violating any criminal law  (excluding minor traffic violations)?        YES         NO

IF THE ANSWER TO ANY OF THE ABOVE IS YES, PLEASE PROVIDE A FULL EXPLANATION OF THE DETAILS ON A SEPARATE SHEET AND ATTACH.

CLINICAL REFERENCES

Please supply MISA with names and addresses of three references.  One must be a physician, one an employer, and a peer of your choice who can attest to your clinical competence.

1.                                                                                                                                            

            Name                                                               Address

                                                                                                   (      )                        

            City                                                     ST           ZIP                  TELEPHONE

2.                                                                                                                                            

            Name                                                               Address

                                                                                                   (      )                                     City                                                     ST           ZIP                 TELEPHONE          

3.                                                                                                                                            

            Name                                                               Address

                                                                                                   (      )                        

            City                                                     ST            ZIP                 TELEPHONE

Please sign the clinical reference form to be mailed to your listed references.   One must be from an employer, one from a non-employer physician, and one from another physician or a peer of your choice who can attest to your clinical competence and adherence to accepted ethics based on their personal knowledge of your professional activities.

It is your responsibility to sign the authorization and release section of this reference form.  References to whom you are related or professional partners are not acceptable references.

AUTHORIZATION AND RELEASE

I understand and agree that by applying to Meridian Institute of Surgical Assisting, Inc. it is my responsibility to provide accurate and sufficient information to enable them to evaluate my qualifications and eligibility, including information regarding my education, licensure, training, experience, competence, professional ethics, morals, character, physical and mental health status, and such other information as may be requested by Meridian.

I do hereby authorize all hospitals and their medical staffs, all health care institutions, educational institutions, persons, peer review organizations, professional liability insurance companies, and other entities with which I have been associated, as well as their respective representatives (collectively “Third Parties”), to consult with and release to Meridian, or its respective representatives, any relevant information they may have concerning my qualifications, eligibility, and the matters contained in this application.

I further agree that if my professional liability insurance is canceled or modified, Meridian will be notified immediately.

I do hereby release Meridian, and its respective representatives, and all Third Parties who provide information as authorized herein, and grant them immunity from any and all liability or claims I may otherwise have for acts performed in connection with their investigation of this Applicant and my qualifications and their release of information.  This Release is in addition to any other immunities or protections for such institutions and individuals provided by law for peer review activities or otherwise.

The authorizations contained herein are irrevocable as long as I am an applicant for Meridian Institute of Surgical Assisting, Inc.

The information contained in this Application is correct and complete in all respects.  I understand and agree that any incorrect information in, or omission of material information from, this Application may be grounds for denial of this Application.

I acknowledge that the information developed during the processing of this Application is confidential to the maximum extent permitted by law.  A photocopy of this document shall be as effective as the original.

I have read, understand, and agree with the foregoing.

_____________________________________________________________________________________                   PRINTED NAME OF APPLICANT                          SIGNATURE OF APPLICANT         DATE

Section below to be completed by Department of Academics:

Application approved ____ Y ____ N

Signature: _______________________________________________________________