Application for
Certified Clinical
Medical Assistant
Cumberland Salem Workforce Education Alliance
Certified Clinical Medical Assistant Program
The Clinical Medical Assistant works in a physician’s office or a clinic setting. As a Clinical Medical Assistant you will be trained to help the doctor carry out procedures, care for patients, perform basic lab tests and administer medications. This course combines classroom
instruction, including electrocardiography (EKG), with a 160 hour externship to provide you with a complete learning experience. Increasing utilization of medical assistants in the rapidly growing healthcare industry will result in fast employment growth for the occupation.
Applicants must apply to this program and a limited number of students will be selected. Eligible applicants must have a high school diploma or equivalent, pass a basic skills math and reading test, and complete a background check. A non-refundable application fee of $75 is required.
Upon successful completion of this course, you will receive a certificate of completion as having met the training requirements of the Clinical Medical Assistant. Graduates will take the
certification examination for Medical Assistant offered by the National Healthcare Association (NHA). This Program was designed to provide thorough didactic and practical instruction, and a basic systems overview of the role of the medical assistant in a practical setting. Didactic lectures cover the theory, anatomy and terminology pertaining to each system. Practical
instruction provides hands-on training in the listed procedures verified through a skills check-off system.
The course fees include: national certification exam, CPR for healthcare workers, externship placement, background check and a certificate of completion.
Application Instructions
1) All information given on the application form must be typed or neatly printed.
2) The completed application, and any subsequent correspondence, must be mailed to
the Cumberland Salem Workforce Education Alliance, PO Box 1500, Vineland, NJ 08362. Attention: Nancy Pollard
3) A check or money order for $75.00, non-refundable application fee must be enclosed.
4) Arrange for an official copy of your high school, GED and/or college transcripts to be forwarded to Cumberland Salem Workforce Education Alliance by calling or
writing to your high school/or assigned designation if your school no longer exists. Copies of high school diplomas are not acceptable.
5) Applicants are required to ask two individuals to provide letters of
recommendation in support of their application (See “Letter of Recommendation”
forms). These references may not be family members. References should be responsible adults who can attest to your ability to successfully complete this training (e.g., employers, instructors, advisors, clergy or medical personnel). References are to be mailed by these individuals to the Cumberland Salem Workforce Education Alliance.
6) Applicants must submit the Immunization & Tests form along with their application, showing proof of Hepatitis B vaccination ( 3 shot series) and recent (one year or less) tuberculin test.
CERTIFIED CLINICAL MEDICAL ASSISTANT
PROGRAM APPLICATION
Please type or print clearly and mail to: Cumberland County College, Cumberland Salem Workforce Education Alliance, PO Box 1500, Vineland, NJ 08362. Attention: Nancy Pollard
Name_________________________________________________________________________
Last First Middle
Other/Previous Name (which may appear on records) ________________________________
Address_______________________________________________________________________
Number & Street Apt. Number
______________________________________________________________________________
City State Zip code
Phone: Home: ( ) Work: ( )_____________________________
Social Security Number _________________________________________________________
Date of Birth___________________________ Email__________________________________
How did you hear about our training Program? __________________________
______________________________________________________________________________
Extra Curricular Activities (please list all school, community or religious activities in which you have
participated. Include all offices which you have held and honors you have received.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Give names and address of the two persons to whom you have submitted the recommendation forms. These references must not be family members. The references should be responsible adults who
can attest to your ability to successfully complete this training.
Name___________________________________________ Title/Position___________________ Address_______________________________________________________________________ Phone (___)_______________________________________ Email_____________________ Relationship to Applicant _________________________________________________________ Name___________________________________________ Title/Position___________________ Address_______________________________________________________________________ Phone (___)_______________________________________ Email_____________________ Relationship to Applicant _________________________________________________________ Educational Background
School City Dates Attended Degree
High School __________________________________________________________
College __________________________________________________________
Special Certification __________________________________________________________
Employment
Present Employer___________________________________ Phone (___)________________
Address ___________________________________ Dates of Employment________
Nature of Work ________________________________________________________________
Name of Employer___________________________________ Phone (___)________________
Address ___________________________________ Dates of Employment________
CERTIFIED CLINICAL MEDICAL ASSISTANT
Statement of Interest
Please explain why you wish to work in the health care services field.
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
CERTIFIED CLINICAL MEDICAL ASSISTANT
Certificate of Information
I certify, to the best of my knowledge, that the information supplied on this application is complete and accurate.
Applicants signature_________________________________ Date_____________
Cumberland County College admits students without regard for race, color, creed, sex, age, religion, national/ethnic origin, sexual orientation, disability, pregnancy or military status.
CERTIFIED CLINICAL MEDICAL ASSISTANT
Immunization & Tests
Name _________________________________________ Age________ Sex_________
Address_________________________________________________________________
City ________________________________________ State_______ Zip ________
Immunization & Test History
Vaccine Dose – Date
Hepatitis B 1. / / 2. / / 3. / / Tuberculin Tests
Dates Applied
Arm / Device / Antigen / Manufacturer
/ / /
Date Read Results (mm)
_____________________________________ ________________________________ Signature of Examiner Print Name of Examiner
______________________________________________________________________________ Address
_____________________________________ ________________________________
RELEASE OF INFORMATION FORM
I, (print name) _________________________________________, authorize Cumberland Salem Workforce Education Alliance to release all of my records pertaining to my criminal history, which includes my name, social security number, date of birth, address, and student ID number to IdentityPi.com.
I understand that the use of my records is limited to and in connection with any audit and the evaluation of continuing education programs, and in connection with the enforcement of the federal and/or state laws.
My signature is an acknowledgement that I have read and voluntarily consent to the release of the above-mentioned information.
_____________________________________________ _________________________ Student Signature Date
________________________________________________________________________ Address
___________________________________ ____________________________________ Social Security # Phone Number
*SSN is used for criminal background check purposes only cccreleaseofinformationform
