Respiratory Care Application Workflow - 2022

El Camino College Respiratory Care Application- filing period is March 21st - April 8th, 2022

NOTICE TO ALL APPLICANTS: Due to restrictions and precautions because of COVID-19 all vaccines will be required and a part of the required physical exam and paperwork that will be due by the end of the Spring semester, June 10th 2022. Being fully vaccinated for COVID-19 is a requirement by all clinical facilities no exemptions are permitted.

Please fill out all the required fields and attach supporting documents below.

Legal Name*

First Name

Initial

Last Name

Upload a passport photo here*

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Upload physical exam paperwork if you have it. You have until June 10th to complete and submit.

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To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Home Phone*

Cellphone*

Email*

El Camino Email*

Date of Birth*

El Camino College student ID #*

SS # (last 4 digits)*

Education

Provide educational history below. Please list your colleges starting from your most recent.

You must upload a PDF unofficial transcript of all colleges attended.

Highest Level of Education:*

High School Graduate GED AA/AS BA/BS MA/MS Doctorate I have not earned a High School Diploma or GED or higher degree

How many colleges have you attended?*

I have met a requirement using AP scores.*

Yes No

I am using my AP score/scores to meet this/these requirement(s)*

English 1A Math 150 Psychology 5 Humanities

Other:

Upload AP score report*

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NOTE: be sure that your score report includes your name. To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #1 Information

College name #1*

College #1 city/state*

College #1 years attended*

College #1 major*

Did you graduate from College #1?*

Yes No

Degree earned at College #1*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #1 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #2 Information

College name #2*

College #2 city/state*

College #2 years attended*

College #2 major*

Did you graduate from College #2?*

Yes No

Degree earned at College #2*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #2 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #3 Information

College name #3*

College #3 city/state*

College #3 years attended*

College #3 major*

Did you graduate from College #3?*

Yes No

Degree earned at College #3*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #3 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #4 Information

College name #4*

College #4 city/state*

College #4 years attended*

College #4 major*

Did you graduate from College #4?*

Yes No

Degree earned at College #4*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #4 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College/ University #5 Information

College/ University name #5*

El Camino College

Other:

College/ University #5 city/state*

College/University #5 years attended*

College/ University #5 major*

Did you graduate from College/ University #5 ?*

Yes No

Degree earned at College/University #5*

n/a AA/AS BA/BS MA/MS

Other:

Upload College/University #5 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #6 Information

College name #6*

College #6 city/state*

College #6 years attended*

College #6 major*

Did you graduate from College #6?*

Yes No

Degree earned at College #6*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #6 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #7 Information

College name #7*

College #7 city/state*

College #7 years attended*

College #7 major*

Did you graduate from College #7?*

Yes No

Degree earned at College #7*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #7 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #8 Information

College name #8*

College #8 city/state*

College #8 years attended*

College #8 major*

Did you graduate from College #8?*

Yes No

Degree earned at College #8*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #8 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #9 Information

College name #9*

College #9 city/state*

College #9 years attended*

College #9 major*

Did you graduate from College #9?*

Yes No

Degree earned at College #9*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #9 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #10 Information

College name #10*

College #10 city/state*

College #10 years attended*

College #10 major*

Did you graduate from College #10?*

Yes No

Degree earned at College #10*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #10 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #11 Information

College name #11*

College #11 city/state*

College #11 years attended*

College #11 major*

Did you graduate from College #11?*

Yes No

Degree earned at College #11*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #11 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #12 Information

College name #12*

College #12 city/state*

College #12 years attended*

College #12 major*

Did you graduate from College #12?*

Yes No

Degree earned at College #12*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #12 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #13 Information

College name #13*

College #13 city/state*

College #13 years attended*

College #13 major*

Did you graduate from College #13?*

Yes No

Degree earned at College #13*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #13 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #14 Information

College name #14*

College #14 city/state*

College #14 years attended*

College #14 major*

Did you graduate from College #1?*

Yes No

Degree earned at College #14*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #14 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

College #15 Information

College name #15*

College #15 city/state*

College #15 years attended*

College #15 major*

Did you graduate from College #15?*

Yes No

Degree earned at College #15*

n/a AA/AS BA/BS MA/MS

Other:

Upload College #15 transcript*

No File Chosen

File uploads may not work on some mobile devices.

To save as a PDF document, you will need to select Print the printer should be set up as SAVE as PDF. Here is an example of what it should look like: https://drive.google.com/file/d/1klaW92oghO0dtEAK2no0xmy79HP0IrKc/view?usp=sharing

Work and/or Volunteer and Observation Experience

Criteria for Additional Points

Must be completed within the last 7 years from the date of the application to receive points.

Please indicate by checking the box in any of the areas below and then associated box will appear for you to include information and supporting documentation for point consideration.

Criteria for Additional Points- Select all that apply to you (remember you must include the information about each area in the associated boxes and upload supporting documentation to receive points)*

# 8 Caregiver for relative with chronic respiratory condition. 2-10 points (2 points per year) #9 Associate degree in health profession (degree related to practice RC) (1-3 points) #10 Other Health Occupations work experience with direct patient care > 1000 hours (5 points) #11 RT Program-Clinical Experience (returnees or transfers) >500 hours (5 points) >150 hours (3 points) #12 Other work experience while attending college (2 points) #13 Observation hours in Respiratory Care >40 hours (3 points) 25-39 hours (2 points) #14 Re-application (non-selection for clinical portion from before) (2 points) #15 Community Service or Service to ECCRC >500 hours (1 point) none

Criteria #8- List details: description of experience, name, email and phone number of someone that can verify. Complete only if applicable.

Criteria #8- Upload supporting documentation

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Criteria #9- List details: description of experience, name, email and phone number of someone that can verify. Complete only if applicable.

Criteria #9- Upload supporting documentation

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Criteria #10- List details: description of experience, name, email and phone number of someone that can verify. Complete only if applicable.

Criteria #10- Upload supporting documentation

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Criteria #11- List details: description of experience, name, email and phone number of someone that can verify. Complete only if applicable.

Criteria #11- Upload supporting documentation

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Criteria #12- List details: description of experience, name, email and phone number of someone that can verify. Complete only if applicable.

Criteria #12- Upload supporting documentation

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Criteria #13- List details: description of experience, name, email and phone number of someone that can verify. Complete only if applicable.

Criteria #13- Upload supporting documentation

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Criteria #14- List details: description of experience, name, email and phone number of someone that can verify. Complete only if applicable.

Criteria #14- Upload supporting documentation

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Criteria #15- List details: description of experience, name, email and phone number of someone that can verify. Complete only if applicable.

Criteria #15- Upload supporting documentation

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Background Check

Go to https://discover.castlebranch.com/

Click on Place Order, enter code: LC38

Enter information on castlebranch site and pay your fees place order.

Complete information below.

Click here to view additional instructions

List date you went on the castlebranch website and placed order for background check and paid fees.*

List your ID for the site*

List your password for the site*

Upload report showing "no convictions" or "no records found"*

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Signature*

[clear]

Use your mouse or finger to draw your signature above

Certification*

I certify that the information submitted in this application is true and correct to the best of my knowledge. I further understand that any false statements may result in denial or revocation of this application.

Counselor section- Respiratory Care Application

Verification of coursework

Upload completed Respiratory Care Verification form*

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Upload completed Respiratory Care Points Worksheet*

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Total Points received for RC Points Worksheet

Verification completed by*

Final Review by Respiratory Care department

Total points from RC Program Application Points Worksheet*

Total points from Work and/or Volunteer and Observation Experience*

Documentation reviewed and verified by:*

First Name

Last Name

RC Faculty Signature*

[clear]

Use your mouse or finger to draw your signature above

Total points for application*