STECH Surgical Technology Program Application
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have a High School Diploma or GED?
*
Yes
No
Do you have a current CPR certification?
*
Yes
No
Do you have any of the following certifications?
*
Certified Nursing Assistant (CNA)
Medical Assistant (MA)
Emergency Medical Technician (EMT)
Phlebotomist
None
Other
Upload a Copy of any Certifications (If applicable)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
References
*
I am responsible to provide a minimum of three (3) reference evaluations to be completed prior to the application deadline.
Three references are required. Please submit up to five names and email addresses.
*
Education
*
Include high school(s) and college/universities attended, dates attended and degrees received if applicable.
Healthcare Work or Volunteer Experience
Include the name of the agency, address, position and job description, and the start and end date that you worked there. List the most recent work experience first.
What interests you specifically about surgical technology, rather than healthcare in general?
*
Please provide a thoughtful response to the question in 150 words or less.
0/150
What kind of teammate would your coworkers or classmates say you are?
*
Please provide a thoughtful response to the question in 150 words or less.
0/150
What motivates you to continue when things get difficult?
*
Please provide a thoughtful response to the question in 150 words or less.
0/150
Describe an experience that changed the way you handle responsibility, stress, or accountability.
*
Please provide a thoughtful response in 150 words or less.
0/150
Why do you believe you would be a strong fit for this program?
*
Please provide a thoughtful response to the question in 150 words or less.
0/150
Are you being sponsored by a facility?
*
Yes
No
If yes, upload documentation of facility sponsorship.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Acknowledgement & Signature: By signing below, I signify my understanding of the significant commitment of time, resources and work to complete a Surgical Technology Program. With that understanding, I choose to pursue the Southwest Tech Surg Tech Program with my best effort.
*
Submit
Should be Empty: