Medical Assistant Program Application

Asterisk (*) indicates a response is required.

NOTE: If you have not contacted a EICC advisor please do so at: eiccinfo@eicc.edu or toll-free: 1-888-336-3907 to sign up for general Education classes for the Pre Medical Assistant program.

General Ed classes are: Bio 163 or Bio 157, and SPC 170, or SPC 112 or ENG 105 or ENG 107 and HSC 113 Med Tem and CPR (need to be current within 1 year of Extern) as listed on the Medical Assistant Fact Sheet.

Student Information

*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Country:
*E-mail:
*Phone Number:
*Select your first choice of classes which you would like to attend::

Spring 2025 | T, Th | 10 a.m. - 2 p.m. | Belmont

The class is held in a "hybrid" format, meaning students receive lab training in person at the college, while completing much of their coursework online.

The student will need a laptop and internet access to complete the program. Canvas knowledge is necessary. Please speak with Advisor about Online Canvas training.

Academic Records

*Who referred you to this form?
*Are you working with an advisor? Yes No
*If yes, who is your advisor
*Most Recent Academic Institution:
*Institution's City:
*Institution's Country:
*Please list any awards you have received:
*Do you have a current BLS AHA CPR card? If not please complete at EICC or other location. Yes No
*Do you have a current First Aid card?: Yes No
*Are you a Certified Nursing Assistant (CNA)? Yes No
Students with CNA or Health Care experience are given priority admission.
*If yes, what is your registration number?
*Have you completed the Child and Adult Iowa Abuse Training at training.hs.iastate.edu/ ? Yes No
If not please make a profile and complete Adult Abuse and Child Abuse.
*Are you in good standing with the Law? Yes No
(Background check is completed prior to Externship)
*Have you been convicted of a felony? Yes No
*Have you applied to EICC?: Yes No
If not, please apply at www.eicc.edu/apply

College Classes

Have you taken college level courses in any of the following and if so, when and where?

*Have you taken Essentials of Anatomy and Physiology or Human Biology (EICC Bio 163 or Bio 157), or other Biology courses? Yes No
*If yes, when (year)?
*If yes, where (college)?
*Please list the Biology course taken:
*Have you taken Public Speaking/Speech (EICC SPC 170) or English Composition/Technical Writing (EICC ENG 105, ENG 107, SPC 112) Yes No
*If yes, when (year)?
*If yes, where (college)?
*Have you taken Medical Terminology (EICC HSC 113)? Yes No
*If yes, when (year)?
*If yes, where (college)?
*Are you currently working in a Health care field? Yes No
*Please describe your Health care experience.
*Other information or suggestions for the Medical Assistant program.

It is the policy of Eastern Iowa Community College District not to discriminate in its programs, activities, or employment on the basis of race, color, national origin, sex, disability, age, sexual orientation, gender identity, creed, religion, and actual or potential family, parental or marital status, as required by the Iowa Code §§216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C. §§ 1681-1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).

If you have questions or complaints related to compliance with this policy, please contact EICC’s Equal Employment Opportunity Officer/Equity Coordinator, Eastern Iowa Community College District, 101 West Third Street, Davenport, Iowa 52801, 563-336-5222, equity@eicc.edu or the Director of the Office for Civil Rights U.S. Department of Education, John C. Kluczynski Federal Building, 230 S. Dearborn Street, 37th Floor, Chicago, IL 60604-7204, Telephone: (312) 730-1560 Facsimile: (312) 730- 1576, TDD (800) 877-8339 OCR.Chicago@ed.gov.

For gainful employment information go to eicc.edu/gainfulemployment