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ST.

BERNADETTE OF LOUR DES COLLEGE


DIALYSIS AND EDUCATION CENTER

(Do not fill this block)

TOR (If College Grad) Y N NA Letter of Recommendation Y N


HS Diploma (If HS Grad) Y N NA Remarks __________________________________
________________________________________

Application will not be processed if all blanks will not be filled out completely and required documents are submitted.
False information automatically invalidates the application.

Admission to the St. Bernadette of Lourdes College Dialysis and Education Center for Dialysis Technician Training is
based on merits and on the compliance to the criteria established by the committee on admission of the school.

Please note that an applicant can choose if Theory Class Only is applicable to current Dialysis Technician with working
experience needing review only, unless otherwise a student does not have any working experience as a Patient Care
Technician then Both Class i.e. Theory Class and Clinical Exposure is required for the student to enroll for issuance of
Completion Certification.

Please do not fall prey to unscrupulous personnel / individuals who will offer their help to facilitate your admission to
the Dialysis Technician Training of any financial / material considerations. We shall appreciate your reporting to the
Education Coordinator of such attempt. We also discourage an applicant wishing admission from offering gift/s of any
kind to anybody connected to the school.

_______________________________
Signature of Applicant

Received by: ___________________

Date : __________________

SBLC-ADM (1)
04-17-10
ST. BERNADETTE OF LOUR DES COLLEGE
DIALYSIS AND EDUCATION CENTER

DIALYSIS TECHNICIAN TRAINING APPLICATION FOR ADMISSION


____ BATCH (___, 20___ - ____20___)

1. Name (Please Print) ___________________________________________________________________________


SURNAME GIVEN NAME MIDDLE NAME

2. Address ____________________________________________________________________________________

3. Date of Birth ____________________________ 4. Place of Birth _________________________

5. Religion _____________________________

6. Age ___________ 7. Sex _________ 8. Height (cm) _____ 9. Weight (kg) _______

10. Civil Status _______________ 11. Nationality and Citizenship ______________________________

12 . EDUCATIONAL ATTAINMENT
LEVEL OF EDUCATION SCHOOL/UNIV ERSITY ADDRESS INCLUSIVE DATE HONORS RECEIV ED
(put n/a if not
applicable)

A. Elementary

B. High School

C. College

EXTRA CURRICULAR ACTIVITIES:

* For questions 13-17, please mark a in a box if applicable*

13. Cont act Person (In case of Emergency that the school can notify) _________________________
Contact Number for this Person ____-________-_____ Cell Work Home
14. Have you applied for Dialysis Technician Training admission in other institutions? Yes No

15. Are you currently working as a Dialysis Technician or Patient Care Technician? Yes No

16. If yes to number 15, ple ase provide the name of facility or clinic are you working with? ______________________

17. Total Number of years experience, as a Patient Care Technician or PCT: _____________

18. Mar k which one does apply in for your adm ission in the education center:
Current PCT, and needs Theory Review Only. Needs Both Class, Theory and Clinical Exposure.
(* Note, if not a current PCT, a student cannot check this box)

SBLC-ADM (2)
04-17-10

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