St. Luke's University Health Network

Application Form

Surgical Technology Program Application Form

Contact Information

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Person to be Notified in Case of an Emergency

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Education Information

List High School and Post-Secondary Schools Attended

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First School Attended

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Second School Attended

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Third School Attended

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Fourth School Attended

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More Information

Goals, Background and Character Information

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Ethnic Background (optional)








Other Information



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

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The fee is $20.00

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Credit Card Information

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