Baylor Scott & White Health

General Information

Family/last name

First name

Middle name

Projected entrance into the program

**This information is optional and in no way affects the processing of your application.

Birthdate**

Gender**

Ethnicity**

Asain American

African-American

Native Hawaiian/Pacific Islander

Hispanic

White

American Indian/Alaskan Native

Other (Please indicate below)

Other**

Are you a U.S. citizen?

If no, type of visa

Country of citizenship

Is English your first language?

Current mailing address

* Address line 1

Address line 2

* City

State

* Zip/postal

Phone (Mobile)

* E-mail

Permanent mailing address

* Address line 1

Address line 2

* City

State

* Zip/postal

Education

Education (list in chronological order beginning with the first school attended):

Name of college/university:

Year attended From:

Year attended To:

Degree received:

Date graduated:

Name of college/university:

Year attended From:

Year attended To:

Degree received:

Date graduated:

Name of college/university:

Year attended From:

Year attended To:

Degree received:

Date graduated:

Name of college/university:

Year attended From:

Year attended To:

Degree received:

Date graduated:

Name of college/university:

Year attended From:

Year attended To:

Degree received:

Date graduated:

Name of college/university:

Year attended From:

Year attended To:

Degree received:

Date graduated:

Name of college/university:

Year attended From:

Year attended To:

Degree received:

Date graduated:

If you attended more than 7 colleges/universities please list here:

Will you be considered a 3+1 or 4+1 student?

3+1 = will receive a bachelor's degree in MLS upon completion of this program

4+1 = has a bachelor's degree prior to enrollment in this program

What university will you receive the degree from?

Have you previously applied to our program?

If yes, please explain what you have done since applying to make you a better candidate:

Have you ever been enrolled in a MLS program?

If yes, explain reason(s) for leaving the program and provide the Program Director's name:

List all current or planned course work (not shown on transcript) to be completed before entering the program:

Course title

Credit hours

Semester

College/university

Course title

Credit hours

Semester

College/university

Course title

Credit hours

Semester

College/university

Course title

Credit hours

Semester

College/university

Course title

Credit hours

Semester

College/university

Course title

Credit hours

Semester

College/university

Course title

Credit hours

Semester

College/university

Employment History

List employment history:

BSWH = any Baylor Scott & White facility

Job #1

Employer

BSWH

Supervisor & contact number

Type of work (be specific)

Employment dates

Reason for leaving

Job #2

Employer

BSWH

Supervisor & contact number

Type of work (be specific)

Employment dates

Reason for leaving

Job #3

Employer

BSWH

Supervisor & contact number

Type of work (be specific)

Employment dates

Reason for leaving

Job #4

Employer

BSWH

Supervisor & contact number

Type of work (be specific)

Employment dates

Reason for leaving

Job #5

Employer

BSWH

Supervisor & contact number

Type of work (be specific)

Employment dates

Reason for leaving

Job #6

Employer

BSWH

Supervisor & contact number

Type of work (be specific)

Employment dates

Reason for leaving

Job #7

Employer

BSWH

Supervisor & contact number

Type of work (be specific)

Employment dates

Reason for leaving

Job #8

Employer

BSWH

Supervisor & contact number

Type of work (be specific)

Employment dates

Reason for leaving

Job #9

Employer

BSWH

Supervisor & contact number

Type of work (be specific)

Employment dates

Reason for leaving

Job #10

Employer

BSWH

Supervisor & contact number

Type of work (be specific)

Employment dates

Reason for leaving

Are you currently working while taking classes or did you work when in school?

If so, how many hours per week?

How many semester hours?

Summer only?

Describe any work or volunteer experience in the medical or non-medical laboratory or healthcare field not associated with school:

Volunteer:

Hours/semester

or single event

Work:

Do you wish to work at a Baylor Scott & White facility after graduation

Do you plan to seek an advanced degree in the next 3 years in any of the following:

Which advanced degree?

Medicine

Pharmacy

Dentistry

Physician assistant

Veterinary

Other (please indicate below)

Other advanced degree

Conclusion

I understand that I will be asked to come for an interview at my expense as part of the admissions process.

I understand that my signature authorizes the Baylor Scott & White Medical Center-Temple Program in Medical Laboratory Science to contact any college advisors, former employers, or references.

I CERTIFY that the information on this form is true and correct to the best of my knowledge. I understand that willfully withholding information or making false statements on this application may be used as the basis for dismissal or disqualification from eligibility.

[ clear ]

Applicant's Signature

Essential Functions

In addition to fulfilling the academic requirements, students accepted into the program must:

1) maneuver sufficiently to collect specimens and perform other laboratory tasks in a timely manner;

2) communicate effectively and professionally with peers, staff, faculty, and patients;

3) read and comprehend words, numbers, charts, and graphs;

4) demonstrate written and oral proficiency in the English language without assistance;

5) interpret reactions on slides, plates, and in test tubes visually;

6) exhibit the manual dexterity necessary to collect blood samples, process specimens, operate laboratory instruments and computers, and other aspects of laboratory testing that require hand-eye coordination;

7) meet the assigned schedule of didactic and clinical instructors, including transportation to clinical sites;

8) carry or lift objects weighing up to 15 pounds;

9) work efficiently under stress to make sound judgments and complete all responsibilities;

10) work in an efficient, responsible, and organized manner;

11) demonstrate ethical judgment, integrity, and accountability in the clinical laboratory when dealing with others;

12) exercise cooperation, confidentiality, and attentiveness at all times;

13) correlate, analyze, integrate, and apply information in laboratory testing and management;

14) successfully complete exams and assignments independently, and

15) follow verbal and written instructions to correctly perform laboratory procedures.

Documentation from a qualified physician is required for any disability requiring reasonable accommodations prior to entering the program.

Type your name to confirm:

NOTE: When considering candidates for the Program in Medical Laboratory Science, the Admissions Committee does not consider race, religion, national origin, veteran status, sex/gender, age, sexual orientation, or disability.