Respiratory Care Program Application

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Respiratory Care Program Application

Thank you for your interest in the Respiratory Care Program at Victoria College. If you are ready to begin the journey to a rewarding career and dynamic profession, then the Respiratory Care Program is ready to partner with you. This program is a two-year Associate of Applied Science degree. As a respiratory therapist you will work under the direction of a physician to evaluate, treat, and care for patients with breathing disorders. There are numerous pathways within the profession that you can select, once you have completed your degree and become successfully credentials.

Our program goal is to prepare graduates with demonstrated competence in the cognitive [knowledge], psychomotor [skills], and affective [behavior] learning domains of respiratory care practice as performed by registered respiratory therapists.

The Respiratory Care Program {#200372} is accredited by the Commission on Accreditation for Respiratory Care. You can learn more by visiting the CoARC website at: www.coarc.com

The program is under the direction of Ceci Oldmixon, M.A.Ed., RRT and and JJ Valdez, MSRC;RRT-ACCS. If you would like more information regarding becoming a registered respiratory therapist, you can visit the national profession’s association website at: www.aarc.org or you can make an appointment with Ms. Oldmixon by email: Ceci.Oldmixon@VictoriaCollege.edu or phone: (361) 572-6426.

Personal Information

Applying for Fall of what year?

First Name:

Last Name:

MI:

Date of Birth

Social Security Number

Are there any other names which might appear on a transcript?

Yes

Student Phone Number

Student Email Address

Present Address:

City:

State:

Zip:

Is your permanent address different than above?

Yes

Permanent Address:

City:

State:

Zip:

Education

High School

High School City:

High School State:

Did you graduate?

Yes

List all colleges or universities attended, dates, you attended, and courses completed:

General Information

Scholastic Honors:

List additional medical trianing that you have received: (exp.: CPR/First Aid, Medical Assisting, etc.):

Have you ever been convicted of a crime other than minor traffic violations?
(Note: DWI is not a minor traffic violation)

Yes

Have you ever been treated medically or surgically for any physical and/or mental conditions which would interfere with your ability to function as a respiratory therapist?

Yes

Emergency Information

In case of an emergency, NOTIFY:

First Name:

Last Name:

Home Phone:

Work Phone:

Cell Phone:

Relationship:

Additional Information

I certify that the above statements are true and correct. I understand it is the applicant’s responsibility to verify that the application has been received and all necessary paperwork be completed before May 15th in order to be considered for acceptance into the program.

Participant Acknowledgement and Release of Information Form

The information provided is complete and correct to the best of my knowledge. I agree to abide by Adult Education Program policies, rules and regulations. I further understand the submission of false information is grounds for rejection of my application, withdrawal of acceptance, and cancellation of enrollment. My signature below shall constitute acknowledgement to statistical use of my records of enrollment, progress, credential obtainment, and transition to postsecondary enrollment or employment. My signature below also authorizes use of my personally identifiable information, including my employment and wage information pre, during and post- enrollment for audit, study and evaluation of the Adult Education and Literacy program performance and other state and federally funded programs.

Such programs may include but are not limited to those under the laws administered by the Texas Education Agency and the Texas Higher Education Coordinating Board.

I acknowledge that the Adult Education and Literacy program and that TWC may release personal identifiable information to other local, state, federal, partners and/or stakeholders for verification of state and federal program requirements, performance reporting, audit, evaluation, study and to monitor the programs performance. Participants who are 17 and 18 years of age must have written parental permission or qualify for another exemption from compulsory attendance law. Additional information may be found at: http://www.twc.state.tx.us/twc-website-privacy-security-information#confidentiality

Participant First Name:

Participant Last Name:

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