St. Luke's - Application Form

Contact Information

* Denotes required fields

First Name

M.I.

Last Name

Address

City

State (NY)

Zip Code (12345)

Phone (123-123-1234 x123)

Birthdate (mm/dd/yyyy)

Person to be Notified in Case of an Emergency

First Name

M.I.

Last Name

Address

City

State (NY)

Zip Code (12345)

Phone (123-123-1234 x123)

Birthdate (mm/dd/yyyy)

Education Information

List High School and Post-Secondary Schools Attended

* Denotes required fields

Choose High School Program Pursued Business
College Prep/Academic
GED
General

First School Attended

Name of School

City

State (NY)

Zip Code (12345)

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

Diploma/Degree Received

Second School Attended

Name of School

City

State (NY)

Zip Code (12345)

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

Diploma/Degree Received

Third School Attended

Name of School

City

State (NY)

Zip Code (12345)

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

Diploma/Degree Received

Fourth School Attended

Name of School

City

State (NY)

Zip Code (12345)

Date of Entrance (mm/dd/yyyy)

Date of Leaving (mm/dd/yyyy)

Diploma/Degree Received

Have you taken the SATs? Yes
No

Date to be taken and/or repeated (mm/dd/yyyy)

Goals, Background and Character Information

* Denotes required fields

Educational Goals: Please provide a paragraph explaining your educational goals.

High School Graduate: If you have graduated from high school more than six months ago, please provide a brief chronology of what you have done since graduation. Please include education, personal enrichment and job experience.

Ethnic Background (optional)

Please check all that apply to you. U.S. Citizen
Alaskan Native
American Indian
Asian American or Pacific Islander
Black American (not of Hispanic origin)
Foreign (in U.S. on student or temporary Visa)
Hispanic American (not Puerto Rican)
White American (not of Hispanic orgin)

If Foreign, please list your country of origin

Other Information

How did you hear about this program? (optional) Newspaper advertisement
Word-of-mouth
Other

If Other, Please Specify

Notice of Non-Discrimination Policy

The St. Luke's Hospital Surgical Technology Program is in compliance with applicable federal, state and local laws, regulations and ordinances governing equal opportunity and non-discrimination, including without limitation, Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, as amended, Section 504 of the Rehabilitation Act of 1973, as amended, and the Age Discrimination Act of 1975. The Surgical Technology Program provides equal educational opportunity to qualified applicants and students and does not discriminate on the basis of age, sex, ancestry, race, color, national origin, religion or disability in recruitment or admission, educational programs and policies, housing, scholarships and loan programs, or non-academic services such as recreation, counseling or social activities. The Director of the program is responsible for the implementation and coordination of equal opportunity in the Surgical Technology Program.

Applicant acknowledgment

The submission of this application to the Student Services Department at The Surgical Technical Program at St. Luke’s University Health Network constitutes a signature by the applicant.

Billing Information

* Denotes required fields

The fee is $20.00

Same As Contact

First Name

M.I.

Last Name

Address

City

State (NY)

Zip Code (12345)

Credit Card Information

Credit Card

Card Number (1234-1234-1234-1234)

CVV2

Exp. Date

Additional Locations:

Additional Services:

Additional Programs:

Medical Education

Application Form

Surgical Technology Program Application Form

Contact Information

Person to be Notified in Case of an Emergency

Education Information

First School Attended

Second School Attended

Third School Attended

Fourth School Attended

More Information

Goals, Background and Character Information

Ethnic Background (optional)

Other Information

Notice of Non-Discrimination Policy

Applicant acknowledgment

Billing Information

Credit Card Information

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