Admission Application - Radiation Therapy

Program:
Program:*
- Radiation Therapy (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:
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 ZIP Code
Phone

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 for Radiation Therapy must include at least two (2) allied health program faculty members, if applicable.
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:

Miscellaneous:
Have you ever made application to this program before?
- Yes
- No
If Yes, what year?
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 below, 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 April 1. Portfolio documents include the application, application fee, brief autobiography, official SAT I or ACT score, official high school transcript or documentation of GED, Official transcripts from all postsecondary schools, professional references and documentation of current certification or eligiblity. Incomplete applications and/or those who do not adhere to the deadline dates will be not considered. 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
Application 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
Name
This field is for validation purposes and should be left unchanged.

Admission Application
Radiation Therapy

Step 1 of 6

Program:

Personal Information:

Optional

Mailing Address:

Permanent Address:

Emergency Contact Information:

Education:

College or Post-Secondary School #1

College or Post-Secondary School #2

College or Post-Secondary School #3

Radiologic Technology

Employment:

Employer #1

Employer #2

References:

Reference #1:

Reference #2:

Reference #3:

Reference #4:

Miscellaneous:

Application Instructions:

Admission ApplicationRadiation Therapy

Step 1 of 6

Program:

Personal Information:

Optional

Mailing Address:

Permanent Address:

Emergency Contact Information:

Education:

College or Post-Secondary School #1

College or Post-Secondary School #2

College or Post-Secondary School #3

Radiologic Technology

Employment:

Employer #1

Employer #2

References:

Reference #1:

Reference #2:

Reference #3:

Reference #4:

Miscellaneous:

Application Instructions:

Admission Application
Radiation Therapy