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Admission Application
Rad Tech

All fields are required. If any area on this application is not applicable, please type N/A into the field.

Step 1 of 6

16%

Program:
Program:*
- Radiologic Technology
Personal Information:
Last Name:*
First name:*
Middle Name:
Maiden Name:
Citizenship:
Optional
The following three fields are OPTIONAL and are used for financial aid and student healthcare purposes only.
Date of Birth:
MM slash DD slash YYYY
Place of Birth:
Gender:
- Male
- Female

Mailing Address:
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Permanent Address:
Permanent Address
Same as Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone
E-mail Address:*
Emergency Contact Information:
Emergency Contact:
Relationship:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

Employment:
List previous employers, starting with the last employer, including dates employed.
Employer #1
Name/Address
Business
Employed From
MM/YY
Employed To
MM/YY
Position
Reason for Leaving
Employer #2
Name/Address
Business
Employed From
MM/YY
Employed To
MM/YY
Position
Reason for Leaving
Employer #3
Name/Address
Business
Employed From
MM/YY
Employed To
MM/YY
Position
Reason for Leaving

Miscellaneous:
Have you ever made application to this program before?
- Yes
- No
If Yes, what year?
YYYY
Have you ever been employed in a Health Care environment?
- Yes
- No
Describe your experience; include where you were employed, what your job duties were, and the length of time you were employed at the Health Care facility:
Have you ever volunteered or shadowed in a Radiology or Imaging Department?
- Yes
- No
Describe your experience; include where you shadowed and the length of time you shadowed:
Describe any work you have done for charitable or volunteer organizations. Include what type of Volunteer work, length of time you volunteered, and your motivation for this volunteer work.
Other than authorized days off, how many times in the last six months have you missed a day of work or school
What do you feel are legitimate reasons for missing work or school?
How many times in the last six months have you been late for work/school?
What was the reason(s) you were late?
Have you ever been convicted of a felony or misdemeanor (other than traffic violations)?
- Yes
- No
If Yes, explain what type of conviction:
See Special Consideration section to obtain Ethics Review Pre-application and contact information.
Autobiographical Sketch:
In the space provided, please type a brief autobiography (minimum 500 words). Include your personal history, family background, secondary and collegiate education, reasons for selecting this career, work experiences in the health field, why you are interested in applying for admission to Grady Health System, and other statements that would indicate your attitude, motivation, and interest in this profession.
Application Instructions:
All application portfolio documents must be postmarked by due date listed under application process. Portfolio documents include the application, application fee, official SAT I, ACT score, COMPASS, or ASSET score(s), official high school transcript or documentation of GED, all official university, college, and/or technical college transcripts, and documentation of any current certification including scores. Incomplete applications and/or those who do not adhere to the deadline dates will be disqualified. All documents are mailed to: Admissions Office
Radiation and Imaging Technologies
Grady Health System
80 Jesse Hill Jr. Drive, SE – Box 26095
Atlanta, GA 30303-3050
Registration Fee:*
Non Refundable
Price:
Credit Card*
Confirm
The information submitted on this application is true to the best of my knowledge. I understand that making false statements, submitting an incomplete application portfolio, and/or not adhering to procedures and/or deadline dates will render my application disqualified. Permission is granted to contact references.
- Yes
- No
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Main Phone:
(404) 616-1000

Main Campus:
80 Jesse Hill Jr Drive SE
Atlanta, GA 30303

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