Admission Application - Diagnostic Medical Sonography

Program:
Program:*
- Diagnostic Medical Sonography (Advanced Program)
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:
Mailling 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 ZIP Code
County:
Home Phone:*
Cell Phone
E-mail Address:*
Emergency Contact Information:
Emergency Contact:
Relationship:
Address:
City:
State:
ZIP/Postal Code:
Phone:

Education:
High School Name/Location
Attended From
Attended To
Graduated
Degree/Diploma
Allied Health Education (RN, Radiologic Technology, Radiation Therapy, etc.) if applicable
Name/Location
Attended From
Attended To
Graduated
Degree/Diploma
College or Technical College #1
Name/Location
Attended From
Attended To
Graduated
Degree/Diploma
Major
College or Technical College #2
Name/Location
Attended From
Attended To
Graduated
Degree/Diploma
Major
College or Technical College #3
Name/Location
Attended From
Attended To
Graduated
Degree/Diploma
Major
College or Technical College #4
Name/Location
Attended From
Attended To
Graduated
Degree/Diploma
Major
College or Technical College #5
Name/Location
Attended From
Attended To
Graduated
Degree/Diploma
Major
How were you informed about the School of Diagnostic Medical Sonography?
Date of Critical Test (SAT I), ACT Test, COMPASS test, or ASSET test:
MM slash DD slash YYYY
Score:
Date of Critical Test (SAT I), ACT Test, COMPASS test, or ASSET test:
MM slash DD slash YYYY
Score:
Date of ARRT Exam (if applicable):
MM slash DD slash YYYY
Status
- Anticipated
- Completed
Score:
Date of other U.S. or State Certification Exam (if applicable):
MM slash DD slash YYYY
Status
- Anticipated
- Completed
Score:

References:
List four (4) references who have supervised the applicant a minimum of six months in an evaluating position (such as supervisors, educators, etc.). Friends, relatives, clergy and co-workers are not acceptable references. References must include at least one (1) allied health program faculty member, if you attended an allied health program.
Reference #1:
Reference Name:
Email Address:
Position/Title:
Address:
City:
State:
ZIP/Postal Code:
Reference #2:
Reference Name:
Email Address:
Position/Title:
Address:
City:
State:
ZIP/Postal Code:
Reference #3:
Reference Name:
Email Address:
Position/Title:
Address:
City:
State:
ZIP/Postal Code:
Reference #4:
Reference Name:
Email Address:
Position/Title:
Address:
City:
State:
ZIP/Postal Code:

Admission Application
Diagnostic Medical Sonography

Step 1 of 6

Program:

Personal Information:

Optional

Mailing Address:

Permanent Address:

Emergency Contact Information:

Education:

Allied Health Education (RN, Radiologic Technology, Radiation Therapy, etc.) if applicable

College or Technical College #1

College or Technical College #2

College or Technical College #3

College or Technical College #4

College or Technical College #5

Employment:

Employer #1

Employer #2

Employer #3

References:

Reference #1:

Reference #2:

Reference #3:

Reference #4:

Miscellaneous:

Application Instructions:

Admission ApplicationDiagnostic Medical Sonography

Step 1 of 6

Program:

Personal Information:

Optional

Mailing Address:

Permanent Address:

Emergency Contact Information:

Education:

Allied Health Education (RN, Radiologic Technology, Radiation Therapy, etc.) if applicable

College or Technical College #1

College or Technical College #2

College or Technical College #3

College or Technical College #4

College or Technical College #5

Employment:

Employer #1

Employer #2

Employer #3

References:

Reference #1:

Reference #2:

Reference #3:

Reference #4:

Miscellaneous:

Application Instructions:

Admission Application
Diagnostic Medical Sonography