PMA-IDL & MOABC-IDL Application

Program(Required)

Session Start(Required)

Session: 8:30am – 1:30pm

Preferred Session (check one):(Required)

8:30am to 1:30pm

5:30pm to 10:30pm

This is a preference NOT a guarantee.

Name(Required)

Name must be printed EXACTLY as shown on current Social Security Card. If no middle name, please write N/A.

Date of Birth:(Required)

Preferred Name:

Mailing Address:(Required)

Address(Required)

City State ZIP Code

Home Phone:(Required)

Cell Phone:

Email Address:(Required)

Your Current Occupation:(Required)

Emergency Contact Name:(Required)

Relationship:(Required)

Phone:(Required)

Do you have a physical or learning disability?(Required)

Yes

No

If yes, please describe and list specific accomodations needed to fully benefit from your educational experience:

Previous Education/Personal Information (check one answer per question):

Higher Education:(Required)

Yes

No

Bi-Lingual:(Required)

Yes

No

High School Diploma:(Required)

Yes

No

US Citizen:(Required)

Yes

No

*NOTE: If you are not a U.S. Citizen please be prepared to provide a copy of your permanent residency.

G.E.D.:(Required)

Yes

No

Veteran:(Required)

Yes

No

Have you ever been convicted of a crime?(Required)

Yes

No

If yes, details:

To the best of my knowledge, the above information is correct and accurate:

Applicant Signature(Required)

Date(Required)

Optional

Gender:

Male

Female

Race:

REQUEST FOR HIGH SCHOOL/GED TRANSCRIPT

Please check one:

High School Diploma

GED

Name

Was your name different at the time of completion?

YES

NO

If YES, name used at the time of completion?

Date of Birth

High School or GED Testing Center

Graduation or Completion Year

High School or GED Testing Center – City/State/Zip

City State ZIP Code

I hereby authorize the Institute of Technology to obtain a copy of my High School transcripts or GED.

Applicant Name

Signature

Date

HYBRID LEARNING ENVIRONMENT AND EQUIPMENT ATTESTATION

The Medical Office Administration Billing & Coding – IDL program is a hybrid program – with both on-campus and distance learning (online) requirements. Before acceptance and signing an enrollment agreement to take hybrid classes at Institute of Technology, all applicants applying to a hybrid program must attest to their ability to be successful in a distance learning (online) environment.

Institute of Technology provides each student an Microsoft Surface Pro 2 and Microsoft Go Keyboard from the College at the time of enrollment; per the Supply Fee Disclosure discussed/reviewed during the enrollment or re-enrollment process (through this process, students can opt-out of purchasing all supplies and/or equipment from the College).

With or without the Microsoft Surface Pro 2, the minimum technology specifications are outlined below. Please check the boxes below to acknowledge each requirement pertaining to the learning environment and required equipment (including maintenance and repair).

HYBRID LEARNING ENVIRONMENT AND EQUIPMENT ATTESTATION

The Professional Medical Assistant – IDL program is a hybrid program – with both on-campus and distance learning (online) requirements. Before acceptance and signing an enrollment agreement to take hybrid classes at Institute of Technology, all applicants applying to a hybrid program must attest to their ability to be successful in a distance learning (online) environment.

Institute of Technology provides each student an Microsoft Surface Pro 2 and Microsoft Go Keyboard from the College at the time of enrollment; per the Supply Fee Disclosure discussed/reviewed during the enrollment or re-enrollment process (through this process, students can opt-out of purchasing all supplies and/or equipment from the College).

With or without the Microsoft Surface Pro 2, the minimum technology specifications are outlined below. Please check the boxes below to acknowledge each requirement pertaining to the learning environment and required equipment (including maintenance and repair).

I have read, understand, and acknowledge the hybrid learning environment’s requirements at Institute of Technology by signing below.

Applicant Name(Required)

Signature(Required)

Date(Required)

COVID-19 VACCINATION REQUIREMENT IN HEALTHCARE SETTINGS

Based on the most recent mandate from the Oregon Health Authority, as outlined in Oregon Administrative Rule (OAR) 333-019-1010, on or before October 18, 2021, COVID-19 vaccinations will be required for healthcare personnel, with a few listed exceptions.

Per OAR 333-019-1010, healthcare personnel includes individuals, paid and unpaid working, learning, studying, assisting, observing or volunteering in a healthcare setting.

Failure to follow the guidelines as outlined in OAR 333-019-1010 could prevent you from completing the clinical portion of your education and furthermore could impact your ability to graduate.

By signing below, you state that you understand the attached guidelines outlined in OAR 333-019-1010 and you understand the academic consequences tied to choosing not to get vaccinated.

Applicant Name(Required)

Signature(Required)

Date(Required)

SOCIAL SECURITY NUMBER PROCUREMENT AND USE DISCLAIMER

In the admissions and enrollment process, the applicants Social Security number is used to assist in qualifying the applicant for college admissions and enrollment, and for securing student financial aid. In order to qualify, prior to class commencement, Admissions and/or Financial Aid must review a valid Social Security card.

A Social Security number is not a permanent student identifier and it will not be required for student identification purposes. The Institute of Technology will not disclose the Social Security number of any applicant to anyone outside the college system except as allowed by law or with permission from the individual applicant.

I authorize Institute of Technology to procure my Social Security number and use it for the purposes stated above. I understand that my Social Security number will not be disclosed to anyone except for the purposes stated above, or with my permission for purposes other than those stated above.

Applicant Name(Required)

Signature(Required)

Date(Required)

DISCLOSURE REGARDING BACKGROUND INFORMATION

Institute of Technology (“the Organization”) may obtain information about you from a third party consumer reporting agency for purposes of evaluating your application for participation in an educational program with the Organization or for participation in clinical, experiential, residency, or other education or degree requirements at a health care facility or clinical program, which may be deemed to be “employment purposes” under the Fair Credit Reporting Act (“FCRA”). Thus, you may be the subject of a “consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information about your criminal history, social security verification, motor vehicle records (“driving records”), education or employment history/evaluations, or other background checks.

You have the right, upon written request made within a reasonable timeline, to request whether a consumer report has been run about you and to request a copy of your report. These searches will be conducted by CastleBranch Corporation, 1844 Sir Tyler Drive, Wilmington, NC 28405, 888-723-4263, www.castlebranch.com.

Applicant Name(Required)

Signature(Required)

Date(Required)

ACKNOWLEDGEMENT AND AUTHORIZATION FOR BACKGROUND CHECK

I acknowledge receipt of the separate documents entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by Institute of Technology (the “Company”) at any time after receipt of this authorization and throughout my participation in the educational program or clinical, experiential, residency, or other education or degree requirements, if applicable. To this end, I hereby authorize any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by CastleBranch Corporation, 1844 Sir Tyler Drive, Wilmington, NC 28405, 888-723-4263, www.castlebranch.com. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants only:
Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

New York City applicants only:
By signing this form, you further authorize the Company to provide you with a copy of your consumer report, the New York City Fair Chance Act Notice form, and any other documents, to the extent required by law, at the mailing address and/or email address you provide to the Company.

Washington State applicants only:
You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Applicant Name(Required)

Signature(Required)

Date(Required)

APPLICANT/STUDENT BACKGROUND AUTHORIZATION FORM

All background checks are run electronically; applicable disclosures and acknowledgements will be disclosed and provided prior to being ordered by Institute of Technology. Please note that all background checks MUST be submitted by the applicant and/or returning student PRIOR to completing enrollment or re-entry paperwork.

Applicant Legal First and Last Name:(Required)

Other Legal Names Used:(Required)

Please write “N/A” if no other legal names are used.

Email Address for Electronic Consent:(Required)

Upon review of the provided information, please complete the section below as applicable to you, the applicant.

Select -ONLY- One:(Required)

I have not been convicted of any of the following: Criminal Convictions (including misdemeanor convictions), Major Traffic Offenses (including Driving Under the Influence), Child Abuse, Neglect or Abandonment

I have been convicted of one or more of the following: Criminal Convictions (including misdemeanor convictions), Major Traffic Offenses (including Driving Under the Influence), Child Abuse, Neglect or Abandonment

By completing the information and signing below, I hereby allow the Institute of Technology to perform a check on my background via CastleBranch Corporation, 1844 Sir Tyler Drive, Wilmington, NC 28405, 888-723-4263, www.castlebranch.com.

Applicant Name(Required)

Signature(Required)

Date(Required)

UPLOAD PROOF OF AGE AND PRIOR EDUCATION

Proof of Age(Required)

Max. file size: 128 MB.

This needs to be a valid Government Issued Photo ID, Driver’s License, ID Card, Passport etc. Birth certificates will NOT be accepted! *Uploaded Documents must be clear & legible & what we are asking for in order for you to move forward in the process.

Proof of Graduation

Max. file size: 128 MB.

Needs to be a picture of the diploma, GED certificate, or full page Official Transcript etc. Please reach out to your Admissions Representative with questions about proof of Graduation. College Degree’s will NOT be accepted! *Uploaded Documents must be clear & legible & what we are asking for in order for you to move forward in the process.

Privacy Policy

Clovis / Fresno, CA

Modesto, CA

Redding, CA

Salem, OR

Criminal Justice Programs

Barbering

Business Office Administration

Culinary Programs

Cosmetology

Medical Programs

Technical Programs

Optional

REQUEST FOR HIGH SCHOOL/GED TRANSCRIPT

HYBRID LEARNING ENVIRONMENT AND EQUIPMENT ATTESTATION

HYBRID LEARNING ENVIRONMENT AND EQUIPMENT ATTESTATION

COVID-19 VACCINATION REQUIREMENT IN HEALTHCARE SETTINGS

SOCIAL SECURITY NUMBER PROCUREMENT AND USE DISCLAIMER

DISCLOSURE REGARDING BACKGROUND INFORMATION

ACKNOWLEDGEMENT AND AUTHORIZATION FOR BACKGROUND CHECK

APPLICANT/STUDENT BACKGROUND AUTHORIZATION FORM

UPLOAD PROOF OF AGE AND PRIOR EDUCATION