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Surgical First Assistant (SFA) Program Application for Admissions 2027-2028

Surgical First Assistant Program

Please wait to complete this application if you do not have every answer. It is very important that you fully answer every question accurately to ensure we have all the information needed as this is a vast online program.
1.Student's First and Last Name:(Required.)
2.Gender:(Required.)
3.Student's Mailing Address:(Required.)
4.Previous Applicant: (Have you previously applied to Madisonville Community College's Surgical First Assistant Program?)(Required.)
5.Certifications: (Current Certification(s), Held.)
Check all that apply.(Required.)
6.Surgical Technology Training:
Name(s) of colleges/schools/programs including dates attended where you completed your Surgical Technology Training and/or Surgical Assisting training.(Required.)
7.Do you have an AST membership? If so, please provide your AST membership number below.

Please note that an active AST membership qualifies you for a discounted fee on the **CSFA certification exam**.(Required.)
8.OR Experience:
Mark Only One.(Required.)
9.Specialty Areas:
Check all that apply.(Required.)
10.Clinical Facility:
Name of facility(s) where you plan to perform clinicals if you are selected for the program.(Required.)
11.Has the facility OR Director/Manager/Educator acknowledged your request to perform clinical hours there?(Required.)
12.OR Director/Manager/Educators Last Name:(Required.)
13.OR Director/Manager/Educators First Name:(Required.)
14.OR Manager/Director/Educators Phone Number:(Required.)
15.Facility(s) Address:(Required.)
16.Facility(s) City:(Required.)
17.Facility(s) State:(Required.)
18.Facility(s) Zipcode:(Required.)
19.Employee of Facility:
Are you an employee of the facility?(Required.)
20.Name of contact person for agreements:
Enter the name of the person at your facility that handles clinical affiliation agreements. If unknown, please check with your educator or HR at your facility. Please state if an agreement is already in place and the facility contact person's name.(Required.)
21.Email of the contact person for agreements:
Enter the email for the person at your facility that handles clinical affiliation agreements. If unknown, please check with your educator or HR at your facility.(Required.)
22.Degree:
In addition to the SFA Certificate Program, are you also interested in the AAS in Surgical First Assisting Degree?
For the AAS Degree, there are general education course requirements in addition to the SFA Program courses. You will need to get with your advisor to check if you are eligible for the AAS Degree.
(Answering this question will not change status)
Please visit our website for more information about the AAS degree or certification:
https://madisonville.kctcs.edu/education-training/program-finder/surgical-first-assistant-program.aspx(Required.)
23.Military Service:(Required.)
24.Selection Notification: The Surgical First Assistant Program is a selective admissions program. This means that meeting the minimum admission requirements does not guarantee acceptance. Applicants are evaluated based on the program's selection criteria, and admission is offered to the most competitive applicants as space allows.
Candidates selected for the program will be sent an acceptance email notification along with instructions for submitting documentation needed to begin the program. By selecting "Agree" below, you agree that you have read and understand the statement above.(Required.)
25.If you are selected for the program, you will be required to submit three letters of reference. These should be from your clinical facility(s) or current facility(s) unless you are a new hire. If you are new to the facility, you must obtain three letters of reference from your most recent place(s) of employment.

By checking the box below, you acknowledge that you understand this requirement and will provide the three reference letters if you are accepted into the program.

Please do not submit reference letters unless you have received an official acceptance email.(Required.)
26.I attest that I have read the entire pre-admission information requirements and fully understand what the SFA Program entails.(Required.)
27.Personal Email Address and Phone Number:(Required.)
28.MCC Student Email Address and Student ID, if Applicable:
29.Comments: