Allied Health Application - General

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ALLIED HEALTH APPLICATION FORM - GENERAL

New to CCAC? Please click HERE to complete an Admissions Application and create a CCAC account.

You will then be assigned a unique student ID number.

CCAC Student ID:*

This number is specific to CCAC. Applicant must be registered with the college to receive.

First Name*

Last Name*

Email Address:*

Confirm Email Address: *

Phone:

Use the following format: xxx-xxx-xxxx

Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

DEMOGRAPHIC INFORMATION (For Statistical Purposes Only; Not Used to Determine Admission)

Date of Birth:*

Gender*

Residency Status*

Allegheny County Out-of-County Out-of-State

County Name:*

State if Out-of-State resident:*

Ethnicity*

Race*

EDUCATIONAL INFORMATION

Student Status:*

Current CCAC Student Previous CCAC Student Previous Student/Other College

CCAC Campus currently attending:*

CCAC Campus previously attended:*

How many previous institutions have you attended?*

Name of School:*

Name of Program:*

Years Attended:*

Degree or Diploma:*

Name of School: *

Name of Program: *

Years Attended:*

Degree or Diploma:*

Name of School: *

Name of Program: *

Years Attended: *

Degree or Diploma: *

Name of School: *

Name of Program: *

Years Attended: *

Degree or Diploma:*

Highest Level of Education Attempted:*

Major*

Associates Degree

Major*

Bachelors Degree

Major*

Masters Degree

Major*

Doctorate

High School Graduation Year:*

High School Name:*

City & State*

High School

Other:*

Have you taken a science course within the last 10 years?*

Science courses taken in last 10 years: - Copy*

Biology with Lab Physics Chemistry Anatomy & Physiology

PROGRAM INFORMATION

CCAC Allied Health Programs are only available at select campuses. Please select a campus location to identify which ALH programs are offered.

Note: Due to program-specific requirements, some ALH programs may have a separate process and may not be listed on the general ALH application.

Visit the Nursing & Allied Health website if you have any additional questions or wish to contact the selected program's coordinator.

Please select campus:*

Allegheny Boyce South

Allegheny Campus ALH Programs:*

Boyce Campus ALH Programs:*

South Campus ALH Programs:*

Which PHB would you like to attend? *

Braddock Hills Center South Campus

ATTENTION Medical Assistant (MDA) Program Applicants:

Completion of the Certificate program is required before application to the Associate's program.

APPLICATION FOR:

Semester:*

Fall Spring

Year*

Attention Anesthesia Technologist (ANE) Applicants:

The program begins during the Spring term of each academic year.

Applications are accepted on a rolling basis from June 1st until full.

Note: Submissions will not be accepted prior to this date.

Transcripts

A copy of Official Transcripts from previous colleges or universities attended MUST be submitted to CCAC for evaluation following the guidelines on the Transfer of Credits website. Upon receipt of your official transcripts, your transcript will be evaluated and you will receive a Transfer Summary from the Registration Department. Some programs request that a copy of Unofficial transcripts be submitted as an attachment to this application using the attachment upload link provided. Please read the requirements of your selected program carefully.

Please attach a copy of your UNOFFICIAL Transcripts*

No File Chosen

File uploads may not work on some mobile devices.

Please submit all as ONE attachment. (REQUIRED)

Please attach a copy of your UNOFFICIAL Transcripts

No File Chosen

File uploads may not work on some mobile devices.

Please submit all as ONE attachment. (DIT)

Will you be submitting a Transfer of Credits evaluation request?*

Yes No

Have you received confirmation of your Transfer of Credits evaluation?*

Yes No

Please contact Transcripts@ccac.edu to obtain a copy of your confirmation

If you have questions regarding the status of your Transfer or Credits evaluation.

Please attach the following:

Transfer of Credits Evaluation

Transfer of Credits Evaluation*

No File Chosen

File uploads may not work on some mobile devices.

Allied Health Program Essential Functions Requirements

Please visit the Nursing & Allied Health program page to confirm the Essential Function requirements for the program of choice.

Please note that some programs require the submission of a completed Essential Functions Form for the application process.

I have read and agree that I can comply with the Allied Health Programs Essential Functions.*

Yes No

Please complete the following:

Essential Functions Form (MDA)

Essential Functions Form - Medical Assistant

I have completed the form(s) at the provided link.*

Yes No

You are required to complete the form(s) that are available at the provided link. Failure to complete these documents will render your ALH program application incomplete and it will not be processed.

APPLICATION VERIFICATION

Please complete the following form.Verification Form - General

I have completed the ALH Verification form provided at the link above and attest that the information on this application is correct to the best of my knowledge. Any falsification or misrepresentation of any information will be sufficient grounds for my dismissal or termination from the program.*