Surgical Technology Program Application for Admission

"*" indicates required fields

Your Information

VCCS Student ID Number*

Name*

First Middle Last

Other Names

List other name(s) that may appear on transcripts/certifications.

Your VCCS Email Address*

Enter Email Confirm Email

Your Primary Phone Number*

Home Address*

Street Address Address Line 2 City State ZIP Code

Campus applying to:*

Middletown Campus (Middletown, VA)

Fauquier Campus (Warrenton, VA)

Checklist for Completing This Application

Please read each statement below and initial each one to agree to these terms for your application to be considered.

I am enrolled as a student at Laurel Ridge Community College.*

Prior to submitting my application, I have verified that all of my official college and high school transcripts are on file with the Laurel Ridge Admissions and Records Department. I agree to submit my college transcripts via email for the surgical technology application before the published deadline (further instructions will be provided upon submitting this application).*

I have attended a Surgical Technology Information Session and/or have met with a Surgical Technology advisor (highly recommended).*

Academic History

Please fill out the information below in regards to your previous academic history.

High School / GED*

Date Started

Date Ended

Last Year Attended

Graduated?

Pre-Requisite Course: SUR 100*

Completion Date

Grade

Pre-Requisite Course: SDV 100 / 101*

Completion Date

Grade

Pre-Requisite Course: BIO 141*

Completion Date

Grade

Pre-Requisite Course: HIM 111*

Completion Date

Grade

Required TEAS Test*

Completion Date

Score

Do you have any Licenses or Certifications? If so, please list:

Agreement

I affirm that I have reviewed the above information and have met with the Program Director, faculty, and /or an Laurel Ridge advisor concerning the Surgical Technology program. To the best of my knowledge all information is true and correct. I understand that enrollment in the Surgical Technology Program is conditional based on successful completion of a criminal background search, drug screen and fingerprinting.*

CAPTCHA