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CAREER & TECHNICAL EDUCATION STUDENT INFORMATION FOR HEALTH SCIENCE

Please fill out the following information to be considered for the CTE Health Science. After completing the form, save it with your last name and the program area name (Health Science Student Info). Print one copy for yourself or save a copy where you can access it later. Follow the directions below to “drop” a copy of the form in the appropriate program folder. The drop boxes will have a date and time stamped automatically when it is dropped in the box.

*Directions for turning in the forms: From a Klein ISD computer:  Go to StudentShare  Campus Klein Collins  CATE folder  Select your program area folder  Copy and paste your form into the folder

Advanced level courses have a class size limit. All fees listed are subject to change.

In all Advanced Health Science courses the student will: – Provide his/her own transportation to assigned health care facility – Make payment for the required uniform and medical equipment – Make payment for the state board exam – Have completed two semesters of Principles of Health Science with an overall average of 70. – Have an overall 2.0 grade point average. – Demonstrate a good attitude by: o Portraying a willingness to follow instructions given by a person of authority. o Having good attendance. o Respecting punctuality by receiving no disciplinary action for excessive tardies in the preceding semester. o Maintaining good conduct with an average rating of “satisfactory” in conduct. o Possessing good personal hygiene and a willingness to follow a designated dress code. o Having no ISS or OSS assignments. – Clinical Rotations and CNA Students must provide a copy of his/her immunization record including two of the three series Hepatitis B-vaccine, a negative TB skin test or chest x-ray within three months, and a current MMR booster or titre prior to the beginning of the semester. – EMT students must also provide a copy of his/her immunization record including influenza vaccination, Hepatitis B-vaccine series, a negative TB skin test or chest x-ray within three months, and two MMR vaccines one at infancy and one at 12 years, current Tetanus-Diphtheria (Td), and Chicken Pox documentation prior to the beginning of the semester.

Health Science – Clinical Rotations is a comprehensive program for students who have successfully completed Principles of Health Science. Students enrolled in the CLINICAL ROTATIONS will be assigned to various healthcare facilities to perform as clinical interns under the direction of a healthcare professional. Due to the increased amount of responsibility required from this course, a professional code of ethical behavior will be expected from every Health Science Technology student. Current costs: malpractice insurance -- $14.50; uniform – price varies.

Problems and Solutions in Health Science -- Certified Nurse Assistant – is a comprehensive program for students who have successfully completed Principles of Health Science. Students enrolled in the CNA program will complete the required state curriculum and be prepared to take the state CNA certification exam. Due to the increased amount of responsibility required from this course, a professional code of ethical behavior will be expected from every CNA student. Permission for background checks required. Current costs: State exam -- $93.00; Malpractice Insurance -- $14.50; uniform (navy) – price varies.

Practicum in Health Science -- Emergency Medical Technician – is a comprehensive program for students who have successfully completed Principles of Health Science. Students enrolled in the EMT program will complete the required state curriculum and be prepared to take the national registry EMT certification exam. Due to the increased amount of responsibility required from this course, a professional code of ethical behavior will be expected from every EMT student. Permission for background checks required. Current costs: $300.00 plus uniform and basic supplies and certification test fee.

of 3 Problems and Solutions in Health Science -- Pharmacy Technician – is a comprehensive program for students who have successfully completed Principles of Health Science. Students enrolled in the Pharmacy Tech program will be able to take the Pharmacy Tech certification exam once they receive their high school diploma and submit full disclosure of all criminal actions. There is a fee for taking the exam which is due when application for the exam is made. Nominal fee for workbook, background check, and fingerprinting is also required. Please fill in the following information:

Select which class(es) you are applying for. If applying for more than one, rank 1st, 2nd and 3rd choice: Health Science Problems and Solutions in Health Science – CNA Problems and Solutions in Health Science – Pharmacy Tech Practicum in Health Science -- EMT

Name Age Date Student ID # Social Security # Current Grade Level Date of Birth Cell Phone: Home Phone # Address Email address: Relative’s Name Relative’s Phone # Father’s/Guardian’s Name Address Phone # Mother’s/Guardian’s Name Address Phone # Do you have transportation? Yes No If not, will you have transportation by August 1, 2011? Yes No

Tell how you will get to your specified program area if not on school grounds: Please list your previous employment and dates of employment:

Approximately how many days of school did you miss this year? If above 10, please list reason: How many times were you sent to the office for discipline problems this year? Why were you sent — for example tardiness? Please tell your reasons for wanting to participate in the Health Science Technology program.

List hobbies, interests, and/or talents you have: Do you plan to continue your education in this field beyond high school? Yes No What are your plans after high school? Technical training, preferred school Military, preferred branch Two year college, preferred colleges Four year university, preferred universities Other, explain

of 3 Are you currently employed? If yes, where do you work? Job Title Supervisor’s Name Phone # How long have you been employed here? List your job responsibilities List two current teachers other than Health Science as references:

Teacher Course

The Klein independent School District does not discriminate on the basis of age sex, handicapping conditions, race or national origin in the education programs or activities which it operates. The Klein Independent School District is an equal opportunity employer.