Radiologic Technology Program Admission Form

DELGADO COMMUNITY COLLEGE IS AN EQUAL OPPORTUNITY FACILITY. DELGADO COMMUNITY COLLEGE DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, GENDER, AGE OR QUALIFIED DISABILITY. SUCCESSFUL ENTRY AS A STUDENT IN THE PROGRAM OF RADIOLOGIC TECHNOLOGY WILL BE BASED UPON THE MERITS OF PAST EDUCATION, EXPERIENCE, RESPONSES TO THE QUESTIONS ON THE APPLICATION FORM AND POSSIBLE INTERVIEW.

Incomplete applications will not be processed.

You must make a copy of this application to turn in with your Transcripts, Narrative and the Technical Standards form.

PERSONAL DATA:
last, first, MI
Number & Street
Area Code and Number
Where will you reside WHILE ATTENDING the RADT program? If different from mailing address.
Number & Street
EDUCATIONAL DATA:
Include: Name of School, Location, Grade Entered, Grade Completed & Year Graduated
Include: Name of School, Location, Major, Month/Year Started, Month/Year Ended, Degree Awarded
Are you presently enrolled in college?
EMPLOYMENT DATA:
include the start and end dates of employment
Are you reapplying for this program?
Are you a veteran of the US Military Service?
Are you a member of the National Guard or Reserve?
Have you ever been suspended or dismissed from any college or university for scholastic or disciplinary reasons?
Are you a U.S. Citizen?
Have you ever been charged with, convicted of, pled guilty or no contest, received a suspended sentence or had adjudication withheld in connection with a FELONY or MISDEMEANOR violation of a state or federal statute? Misdemeanor speeding convictions not related to alcohol or drug use are not required to be reported
Are you able to travel 55 miles to clinical practicum site, if necessary?

ALL APPLICANTS PLEASE READ CAREFULLY AND SIGN THE FOLLOWING:

I UNDERSTAND THAT THE INFORMATION SUBMITTED ON THIS APPLICATION FOR ADMISSION TO DELGADO COMMUNITY COLLEGE’S ALLIED HEALTH PROGRAM IN MY NAME WILL BE RELIED UPON BY DELGADO COMMUNITY COLLEGE OFFICIALS TO DETERMINE MY STATUS FOR ADMISSION ELIGIBILITY. I AUTHORIZE DELGADO COMMUNITY COLLEGE OFFICIALS TO VERIFY ANY INFORMATION I HAVE PROVIDED. I FURTHER AUTHORIZE ANY AND ALL EDUCATIONAL INSTITUTIONS, GOVERNMENTAL AGENCIES, AND PRIVATE EMPLOYERS THAT I HAVE ATTENDED, WORKED FOR, OR WHO MAINTAIN RECORDS RELATED TO ME TO RELEASE SUCH INFORMATION TO DELGADO COMMUNITY COLLEGE.

I AGREE TO NOTIFY DELGADO COMMUNITY COLLEGE’S ALLIED HEALTH ADMISSIONS OFFICE OF ANY CHANGES TO THE INFORMATION PROVIDED.

I CERTIFY THAT THE INFORMATION IN THIS APPLICATION IS COMPLETE AND CORRECT AND UNDERSTAND THAT SUBMISSION OF FALSE, INCOMPLETE, OR INCORRECT INFORMATION IS GROUNDS FOR REJECTION OF MY APPLICATION, WITHDRAWAL OF ANY ACCEPTANCE OFFER, CANCELLATION OF ENROLLMENT, OR APPROPRIATE DISCIPLINARY ACTION. I UNDERSTAND IT IS ALSO NECESSARY TO COMFORM TO THE PROGRAM’S TECHNICAL STANDARDS AND REQUIREMENTS CONCERNING A PHYSICAL EXAMINATION.  IF ACCEPTED, I AGREE TO ABIDE BY AND OBSERVE ALL PROGRAM AND AFFILIATE HOSPITAL POLICIES, RULES AND REGULATIONS, AS AMENDED FROM TIME TO TIME.

I ALSO UNDERSTAND THAT THIS APPLICATION IS FOR THIS PROGRAM ONLY. IF I ENTER DELGADO COLLEGE, I MUST FILL OUT AND SUBMIT A DELGADO COLLEGE APPLICATION FOR ADMISSION. COMPLETION OF THIS FORM DOES NOT INDICATE THAT YOU ARE ACCEPTED INTO THE PROGRAM.

Type your full legal name and today's date