Schools of Radiation and Imaging Technologies

Admission Application

The Radiologic Technology application period is now closed. If you have already applied, supporting documents must be received by April 30, 2015. The application period will reopen in August 2015.

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

Program:

Program:
Radiation Therapy (Advanced Program)
Sonography (Advanced Program)

Personal Information:

Last Name:
First name:
Middle Name:
Maiden Name:
Social Security #:
Citizenship:
Alien Reg #:

The following three fields are OPTIONAL and are used for financial aid and student healthcare purposes only.

Date of Birth:
Place of Birth:
Gender: Male Female

Mailing Address:

Street Address:
Apt. # or P.O. Box:
City:
State:
ZIP/Postal Code:

Permanent Address:

Street Address:
Apt. # or P.O. Box:
City:
State:
ZIP/Postal 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

College or Post-Secondary School #1
Name/Location
Attended From
Attended To
Graduated
Degree/Diploma
Major

College or Post-Secondary School #2
Name/Location
Attended From
Attended To
Graduated
Degree/Diploma
Major

College or Post-Secondary School #3
Name/Location
Attended From
Attended To
Graduated
Degree/Diploma
Major

Radiologic Technology
Name/Location
Attended From
Attended To
Graduated
Degree/Diploma

If course was not completed, state reason:
How were you informed about the school for which you are applying?
Date of Scholastic Aptitude Reasoning Test (SAT I) or ACT Test:
     Score:
Date of ARRT or other U.S. Certification Exam (if applicable):
Status: Anticipated  Completed

Employment:

List previous employers, starting with the last employer, including dates employed.

Employer #1
Name/Address
Business
Employed From
Employed To
Position
Reason for Leaving

Employer #2
Name/Address
Business
Employed From
Employed To
Position
Reason for Leaving

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 Sonography and 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 March 1: application, application fee, brief autobio-graphy, official SAT I or ACT score, official high school transcript or documentation of GED, and documentation of any current certification including scores.  Official transcripts from all postsecondary schools must be postmarked by April 1.  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

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