Taft College Medical Assisting Program Application (2026) Taft College Medical Assisting Program Application (2026) Taft College Medical Assisting Program Application for the 2026 year. Name(Required) First Last Student ID(Required)AnumberEmail(Required) Enter Email Confirm Email Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you have a valid Social Security Number/ITIN:(Required) Yes No **The California Department of Public Health requires possession of a valid Social Security number or Individual Taxpayer Identification Number (ITIN) to apply for certification. Failure to provide a social security number will result in your application for certification to not be processed.High School Graduate(Required) Yes No GED List all previous colleges and universities attended, dates of attendance, and any degrees or certificates earned. College or University Dates of Attendance from Dates of Attendance to Degree or Certificate Earned Date Awarded Actions Edit Delete There are no Add College or University. Add Add College or University Maximum number of add college or university reached. Have you previously attended a Medical Assisting Program?(Required) Yes No …If Yes(Required)If Yes, Which Program?Do you have previous/current health care background/licensure?(Required) Yes No …If YesIf yes, please describeAUTHORIZATION TO RELEASE INFORMATION FORM(Required) I AGREE to the following program requirements:DRUG & ALCOHOL SCREENING I agree to submit a drug and alcohol screening prior to my admission into the program. I agree to submit to immediate monitored drug and alcohol testing upon request of a program instructor and/or the Director of the program at any time while a student in the program. I understand that drug and alcohol testing shall be requested whenever there is reasonable suspicion that I am under the influence of drugs and/or alcohol. I also understand that all information regarding drug and alcohol testing and resulting rehabilitation will be kept confidential and will be maintained in a file separate from my regular file in the office of the director of the program. CRIMINAL BACKGROUND CHECK I agree to submit a criminal background check prior to my admission into the program. I agree to submit to immediate background screening as directed by the Program at any time while a student in the program. I also understand that all criminal background information disclosing a conviction (or pending charge) will be disclosed to the clinical facilities for qualification, further my results will be maintained in a file separate from my regular file in the office of the director of the program. PERMISSION TO RELEASE Taft College has my permission to release the results from my drug/alcohol test, background screening, physical examination, TB test and immunizations/titers to the clinical education centers to which I am assigned while a student in the program. I understand that this form will remain in effect for the duration that I am enrolled in a Taft College Allied Health Program.
