Mississippi Delta Community College

Health Sciences Application

* Legal First Name
Preferred Name
Middle Name
* Last Name
MDCC Student ID number
* Address 1
* City
* State ---- Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
* Zip Code
* Social Security Number
* Date of Birth year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
* Mobile Phone Number
* Email Address *Email Verification
Please submit an individual application for each program
* For which program are you applying? ---- Phlebotomy (one semester) Health Care Assistant (Fall)(Greenville) Health Care Assistant (Fall)(Greenwood) Health Care Assistant (Fall)(Moorhead)
* Have you taken the ACT? Yes No
Be sure you have submitted the ACT Score to the Admissions Office
Most Health Science programs require a minimum ACT score. Please refer to the program's posted minimum requirements, found on the program's website and also included in the information packet which you will receive via email.
Choose the course/s that you have completed within the last 5 years and received a C or better grade. Anatomy & Physiology I Anatomy & Physiology II Nutrition Microbiology General Chemistry Principles of Chemistry
* Have you ever attended college? Yes No
* List the college/s you attended?
* Have you ever attended a Health Science Program? Yes No
* Which College did you attend?
* Which program did you attend?
* Did you complete this program? Yes No
* When did you complete this program year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
* Do you plan to apply to another Health Science Program this year? Yes No
* Which college do you plan to request admission?
* Which program do you plan to request admission?
* Have you ever been employed in a health care setting? Yes No
* List the Company Name, City, and State.
* Position Held
* Position Start Date year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
* Do you still hold this position? Yes No
* End date of position held? year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
* Do you currently hold a license or certification in a Health Care Field? (Current unencumbered Mississippi LPN License REQUIRED for Accelerated Track to ADN) Yes No
* In which field did you obtain your license or certification?
* Type of License or Certificate? State National Both
* List all states you currently hold a license/certificate.
* Date License or Certificate was obtained? year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
* License or Certificate Number
* Do you understand that if accepted into a Health Science Program you will be required to be fingerprinted by our office for a Healthcare Criminal History background check? **See our Background Information Policy found here on our website** I understand the above information
* Have you ever been denied licensure/certification, had disciplinary action or is action pending against you by the licensure/certification board or any other regulatory agency or certification organization in any state or jurisdiction? Yes No
* Please Explain
* Have you ever been convicted of, plead guilty or plead nolo contendere to any charge(s), or are charges pending against you for a felony or misdemeanor, other than minor traffic violations, in any state or jurisdiction? Yes No
* Please explain?
* Have you ever been convicted of a felony, or plead guilty or plead nolo contendere to a felony of possession or sale of drugs, murder, manslaughter, armed robbery, rape, sexual battery, sex offense, listed in Section 45-33-23(h), child abuse, arson, grand larceny, burglary, gratification of lust or aggravated assault, or felonious abuse and/or battery of a vulnerable adult? Health Care Institutions may, at their discretion, refuse clinical experience. Being unable to attend clinical at some clinical facilities may result in a student failure to progress in their program of study. Please request a personal appointment if you may have a disqualifying offense. Yes No
* Please Explain
* Do you understand that if accepted into a Health Science Program drug testing is required for admission, readmission, and/or progression in MDCC Health Science programs? All testing or screening will be done by certified laboratories who maintain normal chain of custody requirements. Substance screen results must meet all MDCC affiliated clinical agency requirements, and this issue may not be altered or changed by this policy. If a clinical requirement of a provider conflicts with this policy, the clinical agreement shall control. **See our Substance Use Policy found here on our website** I understand the above information
* Do you understand the Health Science Program specific functional skills/abilities that are considered essential for the practice in that Health Care Field? These include: critical thinking, interpersonal skills, verbal and written communication skills, physical mobility, fine motor skills, hearing, vision, and reading competencies. **See our Core Standards here on our website by choosing your selected Health Science Program** I understand the above information
(Completion is optional) Do you require special accommodations to the meet the performance standards? Yes No
List Accommodations
* Any statements made on this application which are false and known to be false by the applicant at the time of making such statements, shall be deemed fraudulent and subjects the applicant to disciplinary proceedings. I understand the above information
* According to Mississippi State Law, an individual may not be eligible for employment in a health care agency if the person has ever been convicted of a felony , or plea guilty to , or plea nolo contendere to a felony of possession or sale of drugs, murder, manslaughter, armed robbery, rape, sexual battery, sex offense listed in Section 45-33-23 (h), child abuse, arson, grand larceny, burglary, gratification of lust or aggravated assault, of felonious abuse and/or battery of a vulnerable adult. I understand the above information
* Professional licensure requirements are found here on our website by choosing your selected Health Science Program** I understand the above information
* I certify that the information on this application is true and accurate. Signer acknowledges that electronic signatures executed in compliance with this application shall be legally binding and enforceable in the same manner as traditional written signatures.

In compliance with Title VI and Title VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972 of the Higher Education Act, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, the Pregnancy Discrimination Act of 1978 and other applicable Federal and State Acts, Mississippi Delta Community College offers equal education and employment opportunities and does not discriminate on the basis of age, race, color, national origin, religion, sex, sexual orientation, gender identity or expression, physical or mental disability, pregnancy, or veteran status in its educational programs and activities or in its employment practices. The following have been designated to handle inquiries regarding these policies: EEOC Compliance/Non-Discrimination: Dr. Steven Jones, Vice President of Administrative and Student Services; 662.246.6304 or EEOC@msdelta.edu. Title IX: Christopher Lee, Dean of Student Services, 662.246.6444 or titleIX@msdelta.edu. Disability Support Services: Darla Poole, Counselor, 662.246.6361 or ADAcompliance@msdelta.edu. The mailing address for the above-named representatives is P.O. Box 668, Moorhead, MS 38761.