CAREER & TECHNICAL EDUCATION
STUDENT INFORMATION FOR HEALTH SCIENCE
Please fill out the following information to be considered for the CTE Health Science. After completing the form, save it
with your last name and the program area name (Health Science Student Info). Print one copy for yourself or save a copy
where you can access it later. Follow the directions below to “drop” a copy of the form in the appropriate program folder.
The drop boxes will have a date and time stamped automatically when it is dropped in the box.
*Directions for turning in the forms:
 Login to LMS
 Click on All Klein Collins High School organization
 Click on CTE Forms 14-15 tab on the left side
 Attach your form to the appropriate area
Advanced level courses have a class size limit. All fees listed are subject to change.
In all Advanced Health Science courses the student will:
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Provide his/her own transportation to assigned health care facility
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Make payment for the required uniform and medical equipment
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Make payment for the state board exam
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Have completed two semesters of Principles of Health Science with an overall average of 70.
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Have an overall 2.0 grade point average.
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Demonstrate a good attitude by:
o Portraying a willingness to follow instructions given by a person of authority.
o Having good attendance.
o Respecting punctuality by receiving no disciplinary action for excessive tardies in the preceding semester.
o Maintaining good conduct with an average rating of “satisfactory” in conduct.
o Possessing good personal hygiene and a willingness to follow a designated dress code.
o Having no ISS or OSS assignments.
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Clinical Rotations and CNA Students must provide a copy of his/her immunization record including two of the
three series Hepatitis B-vaccine, a negative TB skin test or chest x-ray within three months, and a current MMR
booster or titre prior to the beginning of the semester.
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EMT students must also provide a copy of his/her immunization record including influenza vaccination, Hepatitis
B-vaccine series, a negative TB skin test or chest x-ray within three months, and two MMR vaccines one at
infancy and one at 12 years, current Tetanus-Diphtheria (Td), and Chicken Pox documentation prior to the
beginning of the semester.
Health Science – Clinical Rotations is a comprehensive program for students who have successfully completed
Principles of Health Science. Students enrolled in the CLINICAL ROTATIONS will be assigned to various healthcare
facilities to perform as clinical interns under the direction of a healthcare professional. Due to the increased amount of
responsibility required from this course, a professional code of ethical behavior will be expected from every Health
Science Technology student. Current costs: malpractice insurance -- $14.50; uniform – price varies. Urine drug
screening will be required per hospital policy.
Problems and Solutions in Health Science -- Certified Nurse Assistant – is a comprehensive program for
students who have successfully completed Principles of Health Science. Students enrolled in the CNA program will
complete the required state curriculum and be prepared to take the state CNA certification exam. Due to the increased
amount of responsibility required from this course, a professional code of ethical behavior will be expected from every
CNA student. Parental permission for background checks required.
Current costs: State exam and malpractice Insurance -- $125.00; uniform (navy) and equipment – price varies.
Practicum in Health Science -- Emergency Medical Technician – is a comprehensive program for students
who have successfully completed Principles of Health Science. Students enrolled in the EMT program will complete the
required state curriculum and be prepared to take the national registry EMT certification exam. Due to the increased
amount of responsibility required from this course, a professional code of ethical behavior will be expected from every
EMT student. Permission for background checks required.
Current costs: $420.00 plus uniform, basic supplies and licensing fee and finger printing.
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Problems and Solutions in Health Science -- Pharmacy Technician – is a comprehensive program for
students who have successfully completed Principles of Health Science. Students enrolled in the Pharmacy Tech program
will be able to take the Pharmacy Tech certification exam once they receive their high school diploma and submit full
disclosure of all criminal actions. There is a fee for taking the exam which is due at the beginning of the school year. .
Nominal fee for workbook, background check, fingerprinting and registration is also required.
Current costs: Registration --$75.00; Fingerprinting -- $15; Review book -- $60; Certification exam -- $129.00
Please fill in the following information:
Select which class(es) you are applying for. If applying for more than one, rank 1st, 2nd and 3rd choice:
Health Science
Problems and Solutions in Health Science – CNA
Problems and Solutions in Health Science – Pharmacy Tech
Practicum in Health Science -- EMT
Name
Age
Date
Student ID #
Current Grade Level
Date of Birth
Home Phone #
Address
Cell Phone:
Email address:
Father’s/Guardian’s Name
Phone #
Mother’s/Guardian’s Name
Phone #
Do you have transportation?
Yes
No If not, will you have transportation by September 1,2014?
Yes
No
Tell how you will get to your specified program area if not on school grounds:
Approximately how many days of school did you miss this year?
If above 10, please list reason:
How many times were you sent to the office for discipline problems this year?
Why were you sent — for example tardiness?
Please tell your reasons for wanting to participate in the Health Science Technology program.
Do you plan to continue your education in this field beyond high school?
What are your plans after high school?
Technical training, preferred school
Military, preferred branch
Two year college, preferred colleges
Four year university, preferred universities
Other, explain
Yes
No
List two current teachers other than Health Science as references:
Teacher
Course
Teacher
Course
The Klein independent School District does not discriminate on the basis of age sex, handicapping conditions, race or national origin in the education
programs or activities which it operates. The Klein Independent School District is an equal opportunity employer.
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