Surgical First Assistant (SFA) Program Application 25-26

Surgical First Assistant Program Application

Please wait to complete this application if you do not have all answers. It is very important that you fully answer all questions correctly to ensure we have all the information needed as this is a vast online program.

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* 1. Student's Full Name:

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* 2. Student's Mailing Address:

Address

City

State

Zip

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* 3. Previous Applicant: (Have you previously applied to Madisonville Community College's Surgical First Assistant Program?)

Yes

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* 4. Certifications: (Current Certification(s), Held.)
Check all that apply.

CST

CSFA

ST (Non-Certified)

TS-C (NCCT)

CSA

SA-C

CNOR

Other

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* 5. Surgical Technology Training:
Name(s) of colleges/schools including dates attended where you completed your Surgical Technology Training and/or Surgical Assisting training.

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* 6. OR Experience:
Mark Only One.

5+ years

4-5 years

2-4 years

1-2 years

Less than 1 year

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* 7. Specialty Areas:

General

Cardiovascular

Peripheral Vascular

Thoracic

Neurosurgery

OB-GYN

Urology

Plastic

Endosurgery

Ophthalmology

Otorhinolaryngology

Oral/Maxillofacial

Oncology

Pediatrics

Orthopedic

Other

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* 8. Clinical Facility:
Name of facility(s) where you plan to perform clinicals if you are selected for the program.

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* 9. Has the facility OR Director/Manager/Educator acknowledged your request to perform clinical hours there?

Yes

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* 10. OR Director/Manager/Educators Last Name:

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* 11. OR Director/Manager/Educators First Name:

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* 12. OR Manager/Director/Educators Phone Number:

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* 13. Facility(s) Address:

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* 14. Facility(s) City:

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* 15. Facility(s) State:

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* 16. Facility(s) Zipcode:

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* 17. Employee of Facility:
Are you an employee of the facility?

Yes

(Please specify if needed)

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* 18. Name of contact person for agreements:
Enter the name of the person at your facility that handles clinical affiliation agreements. If unknown, please check with your educator or HR at your facility. Please state if an agreement is already in place and the facility contact person's name.

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* 19. Email of the contact person for agreements:
Enter the email for the person at your facility that handles clinical affiliation agreements. If unknown, please check with your educator or HR at your facility. Please state if an agreement is already in place.

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* 20. Degree:
In addition to the SFA Certificate Program, are you also interested in the AAS in Surgical First Assisting Degree?
For the AAS Degree, there are general education course requirements in addition to the SFA Program courses. You will need to get with your advisor to check if you are eligible for the AAS Degree.
(Answering this question will not change status)
Please visit our website for more information about the AAS degree or certification:
https://madisonville.kctcs.edu/education-training/program-finder/surgical-first-assistant-program.aspx

Yes

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* 21. Military Service:

Yes

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* 22. Selection Notification:
Candidates selected for the program will be sent an acceptance email notification along with instructions for submitting documentation needed to begin the program in August. By selecting "Agree" below, you agree that you have read and understand the statement above.

I Agree.

I do not agree.

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* 23. I attest that I have read the entire pre-admission information requirements and fully understand what the SFA Program entails.

I agree.

I do not agree.

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* 1. Student's Full Name:

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* 2. Student's Mailing Address:

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* 3. Previous Applicant: (Have you previously applied to Madisonville Community College's Surgical First Assistant Program?)

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* 4. Certifications: (Current Certification(s), Held.)Check all that apply.

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* 5. Surgical Technology Training:Name(s) of colleges/schools including dates attended where you completed your Surgical Technology Training and/or Surgical Assisting training.

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* 6. OR Experience:Mark Only One.

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* 7. Specialty Areas:

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* 8. Clinical Facility:Name of facility(s) where you plan to perform clinicals if you are selected for the program.

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* 9. Has the facility OR Director/Manager/Educator acknowledged your request to perform clinical hours there?

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* 10. OR Director/Manager/Educators Last Name:

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* 11. OR Director/Manager/Educators First Name:

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* 12. OR Manager/Director/Educators Phone Number:

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* 13. Facility(s) Address:

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* 14. Facility(s) City:

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* 15. Facility(s) State:

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* 16. Facility(s) Zipcode:

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* 17. Employee of Facility:Are you an employee of the facility?

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* 18. Name of contact person for agreements:Enter the name of the person at your facility that handles clinical affiliation agreements. If unknown, please check with your educator or HR at your facility. Please state if an agreement is already in place and the facility contact person's name.

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* 19. Email of the contact person for agreements:Enter the email for the person at your facility that handles clinical affiliation agreements. If unknown, please check with your educator or HR at your facility. Please state if an agreement is already in place.

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* 21. Military Service:

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* 22. Selection Notification:Candidates selected for the program will be sent an acceptance email notification along with instructions for submitting documentation needed to begin the program in August. By selecting "Agree" below, you agree that you have read and understand the statement above.

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* 23. I attest that I have read the entire pre-admission information requirements and fully understand what the SFA Program entails.

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* 24. Comments:

* 4. Certifications: (Current Certification(s), Held.)
Check all that apply.

* 5. Surgical Technology Training:
Name(s) of colleges/schools including dates attended where you completed your Surgical Technology Training and/or Surgical Assisting training.

* 6. OR Experience:
Mark Only One.

* 8. Clinical Facility:
Name of facility(s) where you plan to perform clinicals if you are selected for the program.

* 17. Employee of Facility:
Are you an employee of the facility?

* 18. Name of contact person for agreements:
Enter the name of the person at your facility that handles clinical affiliation agreements. If unknown, please check with your educator or HR at your facility. Please state if an agreement is already in place and the facility contact person's name.

* 19. Email of the contact person for agreements:
Enter the email for the person at your facility that handles clinical affiliation agreements. If unknown, please check with your educator or HR at your facility. Please state if an agreement is already in place.

* 22. Selection Notification:
Candidates selected for the program will be sent an acceptance email notification along with instructions for submitting documentation needed to begin the program in August. By selecting "Agree" below, you agree that you have read and understand the statement above.