RIVERSIDE COUNTY REGIONAL MEDICAL CENTER RIVERSIDE COMMUNITY COLLEGE DISTRICT

MORENO VALLEY COLLEGE PHYSICIAN ASSISTANT PROGRAM

2014 APPLICATION FOR ADMISSION APPLICATION CHECKLIST

Legal Name: Student I.D.:

Please read and follow instructions carefully. Use only the forms provided in this application packet. Additional forms will not be considered. This checklist and the following documents must be submitted as one packet to the RCRMC/RCCD - MVC PA Program. Items submitted under separate cover will not be accepted. It is recommended that you keep a copy of this checklist and your application materials for your record. It is also recommended that you review the Application Frequently Asked questions link on the programs website at www.mvc.edu/academicprogrms/pa to assist you with the application process.

□ 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 in lieu of completing any portion of the application. All application materials must be completed using your legal name.

□ PERSONAL STATEMENT: Typed, double-spaced, font size must be 12 using Times New Roman. Responses must fit in the space allowed. Do not add additional sheets to answer the questions. Failure to comply with these directions will result in denial of your application.

□ VERIFICATION OF OCCUPATIONAL EXPERIENCE: Information must be reasonably verifiable during program hours. 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. This form will not be accepted if any portion of it has been completed by the applicant. Forms must have the original signature of the person verifying your experience. No faxes or photocopies will be accepted. You must include a Payroll Register Detail Report (PRDR) and job description to be considered for enrollment.

□ OFFICIAL TRANSCRIPTS: Must be included with your application packet. Submit official transcripts, no more than 90-days old, from all colleges and universities attended regardless of previous submission for enrollment. Prerequisite coursework completed online will not be accepted. If the applicant has attended Riverside Community College District, RCCD Transcripts must be submitted along with this application. Transcripts are required regardless of whether or not the coursework relates to the Physician Assistant program. This includes coursework completed outside the United States. All transcripts must be in a sealed institution envelope with an Official Transcript stamp or seal on the outside of the envelope. Open envelopes or copies will not be accepted, and will invalidate your application. All transcripts from outside the United States must include a detailed Transcript Evaluation from an International Evaluation Agency such as American Evaluation Research Corp. (www.aerc-eval.com) or International Education Research Foundation (www.ierf.org). The evaluation agency must be located in the United States. All transcript evaluations must not be older than one year. All program prerequisites must be completed and grades must be reported on the transcript at the time of application to the program.

□ RCRMC/RCCD - MVC PA PROGRAM REFERENCE FORMS: Reference Forms are required from two (2) individuals and can only be completed by individuals (i.e., physician, physician assistant, nurse supervisors) who have supervised the applicant in the medical setting. 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. No photocopies, faxes or attachments will be accepted or considered. Applicants: Please inform your evaluator of the specific requirements. Failure to comply will result in denial of your entire application.

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Legal Name: Student I.D.: □ Proof of Residency: In accordance with Riverside Community College District’s Board of Trustees

Policy 5055, your application will be reviewed in order of legal residence. Information regarding this policy may be found on the program’s website at www.mvc.edu/academicprograms/pa. You must provide three proofs of residency that must be dated no more than one year and one day prior to the start of the term for which you are applying. Examples of appropriate documentation are listed below. Those with an asterisk are preferred and may also be requested during the validation process: California voter’s registration card California (540) tax returns giving California as the home address (with acceptable dates) Paycheck stub OR letter of employment verification on company letterhead (signed by a manager of the personnel department) California Driver’s License OR California ID card OR DMV printout California Bank account – checking or savings statements Marriage license or divorce decree issued in California License or certificate issued by the State (with issue & expiration dates) *California utility bill (DWP, gas, telephone, cable - all utility bills count as one proof) California State Aid or Social Welfare California vehicle registration and/or car insurance (California company) California health insurance OR Medi-Cal ID Military discharge papers (DD214) OR Leave and Earnings statement (indicating California as Home of Record) California property taxes (student’s name only) Union membership in a California local *California apartment/home lease or rental agreement (1 year current) California public library membership (verified by letter or printout with letterhead or branch stamp).

□ RCCD ADMISSION APPLICATION: If you are not currently an RCCD student, you must complete the online

application for admission to Moreno Valley College (Please select as your “home” college). Access the application at http://www.rccd.edu/services/admissions/Pages/ApplyNow.aspx. You may also copy and paste the link into your browser. You must apply to the college prior to submitting the RCRMC/RCCD – MVC Physician Assistant program application. Print and submit a copy of the confirmation page with this application after applying.

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/RCCD MVC 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/RCCD MVC Physician Assistant Program and that the RCRMC/RCCD - MVC 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 Application may be used for research purposes. I understand that the RCRMC/RCCD MVC Physician Assistant program has procedures in place to protect the anonymity and confidentiality of the information provided on the Application for Admission. Applicant Signature: Date: Completing the following demographic information is optional and is used solely for program data collection, grants and professional research purposes. Age: Ethnicity: Race: Degree: Languages Spoken:

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RIVERSIDE COUNTY REGIONAL MEDICAL CENTER RIVERSIDE COMMUNITY COLLEGE DISTRICT

MORENO VALLEY COLLEGE

PHYSICIAN ASSISTANT PROGRAM

2014 ENROLLMENT APPLICATION

USE ONLY THE FORMS PROVIDED, DO NOT DUPLICATE UNLESS OTHERWISE INDICATED. TYPE OR PRINT LEGIBLY IN BLACK INK.

Legal Name (Last, First, M.I.): ______________________________________ Student I.D.: Other name(s) used: Gender: Male _____ Female _____ Date of Birth: / / Place of Birth: Current Address where you reside: County: Address, City, State, Zip

Mailing address: ___________________________________________________________________________ Home Phone: _______________Cell/Message: __________________ E-mail: _________________________ IT IS YOUR RESPONSIBILITY TO ADVISE THE PROGRAM OF ANY ADDRESS/PHONE NUMBER CHANGES. EDUCATION: (If additional space is needed, copy this sheet and continue listing education information.) College: State: From: To:

Major: Units completed: (qtr) (smstr) GPA:

Degree received: AA AS BA BS MA/MS or N/A (Not Applicable)

Doctoral Degree:____________________Certificate: __________________________Date conferred: _______

College: State: From: To:

Major: Units completed: (qtr) (smstr) GPA:

Degree received: AA AS BA BS MA/MS or N/A (Not Applicable)

Doctoral Degree:____________________Certificate: __________________________Date conferred: _______

College: State: From: To:

Major: Units completed: (qtr) (smstr) GPA:

Degree received: AA AS BA BS MA/MS or N/A (Not Applicable)

Doctoral Degree:____________________Certificate: __________________________Date conferred: _______ College: State: From: To:

Major: Units completed: (qtr) (smstr) GPA:

Degree received: AA AS BA BS MA/MS or N/A (Not Applicable)

Doctoral Degree:____________________Certificate: __________________________Date conferred: _______ TOTAL UNITS COMPLETED: (qtr) (smstr) Cumulative GPA: ____________ High School, City and State: _________________________________________ Graduation Date: ___________ Vocational/Allied Health School: _______________________________________________________________ Degree/Certificate/Diploma: ___________________________________________Year completed: __________

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Legal Name: Student I.D.: _ SKILLS: Check all items that are currently or have previously been part of your job responsibilities. All skills that are checked must correspond with the skills listed on the job description: □ 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 □ Gastric lavage Microscopic evaluation of: □ Taking x-rays □ Blood □ Injections □ Urine □ Venipuncture □ Gram-stained specimens □ Catheterization □ Other PAID, DIRECT PATIENT CARE EXPERIENCE: List all clinical work completed and provide a Payroll Register Detail Report(PRDR) and job description from your employer. If more than one employer is used for paid hands-on experience, a PRDR must be submitted for each employer. To verify hours worked, a Verification of Occupational Experience form (see pages 15 and 16) must be submitted for each employer listed below. All work experience must be completed at the time of application. Job Title: ______________________________Total hours:_____ From Mo/Yr:_______ To Mo/Yr:________

Supervisor’s Name/Title: _______________________________________________ Phone:_______________

Employer’s Address:________________________________________________________________________

Address, City, State, Zip

Description of duties:

Job Title: ______________________________Total hours:_____ From Mo/Yr:_______ To Mo/Yr:________

Supervisor’s Name/Title: _______________________________________________ Phone:_______________

Employer’s Address:________________________________________________________________________

Address, City, State, Zip

Description of duties:

Job Title: ______________________________Total hours:_____ From Mo/Yr:_______ To Mo/Yr:________

Supervisor’s Name/Title: _______________________________________________ Phone:_______________

Employer’s Address:________________________________________________________________________

Address, City, State, Zip

Description of duties:

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Legal Name: _________________________________________________Student I.D.: ___________________

MILITARY SERVICE:

Job Title: _____________________ Location: ____________ Fr. Mo/Yr: To Mo/Yr: Job Title: _____________________ Location: ____________ Fr. Mo/Yr: To Mo/Yr: Discharge Date: Type of Discharge: (Complete the information above and attach a copy of your DD214) CURRENT LICENSES/CERTIFICATIONS: Title: State: Date issued: Expires: Title: State: Date issued: Expires: Title: State: Date issued: Expires:

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Legal Name: Student I.D.: PRIOR ENROLLMENT / DISCIPLINE / CONVICTIONS: (Circle One) 1. Are you currently enrolled in or have you ever been enrolled in a professional Program? Yes No (e.g. Physician Assistant, Medicine, Nursing, Dental or other allied health) 2. If yes, please provide a detailed explanation regarding the outcome in the space provided below. Include the

name of the school and its location. 3. Have you ever been convicted of a crime (other than a minor traffic violation)? Yes No

4. Has a judgment ever been filed against you? Yes No

5. Have you ever withdrew, been disciplined, sanctioned, placed on probation, or dismissed from a program for

any reason (i.e. educational, personal, professional, military, business, or employment)? Yes No

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.

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Legal Name: Student I.D.:

PERSONAL STATEMENT: Type a double-spaced, (300-500 word) response to each of the following questions. You must also include a brief (100 word) statement explaining your financial support plan if you are accepted to the program. Your statements must be typed on this form. A font size less than 12 will not be accepted. Personal statements are evaluated for clarity, spelling and grammar. Failure to comply with these directions will result in denial of your entire application. PLEASE NOTE: IF A PLUS SIGN APPEARS IN THE BOTTOM RIGHT CORNER OF THE BOX YOU ARE TYPING YOUR RESPONSES IN, THEN YOU HAVE EXCEEDED THE SPACE ALLOWED FOR THE RESPONSE. THE WORDS THAT ARE TYPED AFTER THE PLUS SIGN APPEARS CANNOT BE VIEWED BY THOSE REVIEWING THE APPLICATION. ALL RESPONSES MUST BE COMPLETED IN THE SPACE ALLOWED. DO NOT ATTACH ADDITIONAL SHEETS TO COMPLETE YOUR RESPONSES.

1. Why do you want to become a PA? (300-500 words)

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2. What do you feel is the greatest barrier to your academic success? (300-500 words)

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3. What knowledge base, skills and behaviors do you feel are important to be successful in a PA

Program? (300-500 words)

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4. How do you plan to address the financial demands of a full-time program without working? (100

words)

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5. What have you researched or learned about the Physician Assistant profession?

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Legal Name: Student I.D.: PREREQUISITE COURSES:

List all completed prerequisites below. Do not list courses in progress. Prerequisite coursework completed online will not be accepted. All required prerequisite coursework must be completed at the time of application and grades must be recorded on your official transcripts.

Prerequisites

College/Univ. Where Taken

Write Department Name Course Number & Complete Course Title

Sem./Qtr. Units

Year/Term Taken

Final Grade

*Anatomy and Physiology 2A

*Anatomy Lab

*Anatomy and Physiology 2B

*Physiology Lab

*Microbiology 1

*Microbiology Lab

Physics 10

Physics 11

Chemistry 2A

Chemistry 2B

Communications 9

English 1A

Math 12

Math 35

Medical Terminology 1A

*Anatomy, Physiology and Microbiology must include a lab, and have been taken within five years at the time of application. A minimum 3.0 GPA is required for ALL program prerequisites. A minimum 2.0 GPA is required for ALL OTHER, non-program college coursework completed.

THIS LIST IS ONLY A GUIDELINE. ALL COURSEWORK WILL BE REVIEWED FOR EQUIVALENCY AND ACCURACY.

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Legal Name: Student I.D.: PREREQUISITE COURSES CONTINUED:

List all completed prerequisites below. Do not list courses in progress. Prerequisite coursework completed online will not be accepted. All required prerequisite coursework must be completed at the time of application and grades must be recorded on your official transcripts.

Prerequisites

College/Univ. Where Taken

Write Department Name Course Number & Complete Course Title

Sem./Qtr. Units

Year/Term Taken

Final Grade

Medical Terminology 1B

Psychology 1

Sociology 1 or Anthropology 2

Language other than English (Spanish preferred) - One year or equivalency

Language other than English (Spanish preferred) - One year or equivalency

*Anatomy, Physiology and Microbiology must include a lab, and have been taken within five years at the time of application. A minimum 3.0 GPA is required for ALL program prerequisites. A minimum 2.0 GPA is required for ALL OTHER, non-program college coursework completed.

THIS LIST IS ONLY A GUIDELINE. ALL COURSEWORK WILL BE REVIEWED FOR EQUIVALENCY AND ACCURACY.

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Please Note: Errors, omissions, or falsification in any portion of the application or supporting materials will result in denial of your application.

APPLICATION DEADLINE: Monday, January 5, 2015 by 4:00 p.m.

APPLICATIONS MUST BE MAILED DIRECTLY TO THE RCRMC/RCCD MVC PHYSICIAN ASSISTANT PROGRAM AT THE ADDRESS BELOW. DO NOT HAND-CARRY OR USE COURRIER SERVICES TO DELIVER APPLICATION PACKETS TO THE RCRMC/RCCD MVC PA PROGRAM. THE ONLY ACCEPTABLE FORM OF DELIVERY IS VIA U.S. MAIL, UNITED PARCEL SERVICE (UPS), OR FEDERAL EXPRESS (FED EX). APPLICATIONS MUST BE RECEIVED NO LATER THAN JANUARY 5, 2015 BY 4:00 P.M. Note: If you mail your application and signature is required, it may result in serious delay of the PA program’s receipt of your application packet. APPLICATIONS RECEIVED AFTER THE DEADLINE DATE WILL NOT BE CONSIDERED. THIS INCLUDES APPLICATIONS POSTMARKED WITH THE DUE DATE THAT ARE RECEIVED AFTER THE DEADLINE. ADDRESS ALL CORRESPONDENCE TO:

RCRMC/RCCD MVC PA PROGRAM Moreno Valley College 16130 Lasselle Street

Moreno Valley CA 92551-2045 This program complies 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, and Sections 102 and 103 of the Americans with Disabilities Act of 1990. This program does not discriminate on the basis of race, color, national origin, religion, handicap, or sexual orientation in any of its policies, procedures, or practices.

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/RCCD MVC PA Program. I understand that information submitted relative to this application becomes property of the RCRMC/RCCD MVC PA Program. I further understand that the RCRMC/RCCD MVC 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: