Lompoc Adult School Medical Certification Program - Personal Interview Form
Thank you for attending the orientation for LASCC's Medical Programs.

Why complete this form?
This form is to be completed AFTER students have attended LASCC's Zoom Orientation for Healthcare Programs. After the orientation, please complete this form so that we can track your preferences, needs, questions, etc.

This form is used as part of the intake and evaluation of candidates. In addition, all correspondence and meetings with LASCC staff is reviewed.

Not ready to submit this form? 
There is no deadline for you to complete this form. We want students to consider their goals and futures if they are uncertain about choosing to register in one of our medical programs. If you want further help making your decision, you may make an appointment with our Career Technician to get additional guidance.

Currently, the programs that we offer including the following;
  1. Medical Terminology with Anatomy and Physiology
  2. Medical Assistant Certification
  3. Phlebotomy Technician I Certification
  4. EKT Technician Certification
  5. Nursing Assistant Preparation
  • Candidates must be 18 and older and possess a high school diploma or equivalency. Transcripts must be provided.
  • Application processes must be successfully completed.
  • Prerequisites must be successfully completed.
  • Candidates for Certification programs must pass a background check.
  • Candidates with low levels of literacy may need to complete the free, online Literacy for Medical Professionals prerequisite from Lompoc Adult School.
  • All admitted candidates are eligible for a full scholarship to LASCC's programs, so long as funds remain available.
  • Completion of this form does not guarantee placement into the program.
By completing and submitting this form, candidates give permission for Lompoc Adult School and Career Center to communicate candidate status to partner agencies.
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Email *
First Name *
Last Name *
Phone Number *
Please indicate which program(s) you are interested in.
 *
Required
Please list any medical experience and medical certifications that you have: *
Please describe your past five years of employment history. If you have been unemployed for this time period, please explain why. *
Please describe your current employment situation. If you are currently unemployed, please explain why. *
Please explain the improvements in your current employment situation that you would like to see 6-12 months from now after completing our program. *
Please explain the improvements in your employment situation that you would like to see 2-5 years from now after completing our program: *
For candidates who may be seeking a new job: 

For future employment, what are the best shifts that would work for you? Check all that apply:
 *
Required
For candidates who may be seeking a new job:

If you are responsible to care for others, what is the ideal time that you would need to be done working each day?
 *
Required
All candidates who complete our Medical Assistant, Phlebotomy, or EKG Certifications must pay for and complete their certification exam immediately after they complete their programming. Otherwise, no certificate will be issued.

The certification exam process may take up to six hours on a Saturday.

Candidates applying for our school must agree that they will prioritize this step and that they will be able to pay all related fees, which may total between $100 and $200.

Please enter a response to explain any barriers that you may have to this.
 *
Because we are working with other agencies to help bring in more resources to our programs, we ask the following. 

This question helps our school seek additional funding on behalf of students.
 *
Please provide one professional reference from someone who has supervised you and who can recommend you for consideration to our program. Include the person's name, title, and phone and/or email contact: *
If you have questions or comments, please include them below.
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