Application for Admission

Application deadline has been extended to APRIL 1

Federal and State Laws prohibit discrimination based on race, color, religion, sex, age, disability or national origin. No question on this application is asked for the purpose of excluding any applicant because of age, race, color, religion, gender, disability, national origin or any other protected class.

First Name *

Last Name *

Middle

Maiden Name

Address *

Apt#

City *

State *

Zip *

Home Phone *

Work Phone

Mobile Phone

Email *

Social Security Number

Education:

School Name

Course/Major

Diploma/Degree

Are you currently attending school or college?

Yes No

If yes, please specify which one:

Have you applied to any other Radiography programs?

Yes No

If yes, please specify:

Have you ever made application to this program before?

Yes No

If yes, when?:

Military:

Branch of Service

Military Specialty

Reserve Status/National Guard

Employment Experience:

Employer

Position Held

Dates Employed

Hours/Week

Voluteer Experience:

Agency/Facility

Description

Health Related Certifications:

Agency

Name of Certificate

Date Received

Personal Comment

Type an autobiographical essay describing your reasons for seeking admission to this program.

Please Read Carefully and Check the Box Below

I certify to the best of my knowledge that the information provided in this Application for Admission is true and complete and I understand that any misrepresentation or omission of facts called for herein may be cause for terminating my attendance in the program at any time. I hereby release from all liability or damages, those persons, agencies, and organizations that may furnish information in connection with my application for admission. I understand that I must satisfactorily pass a physical examination and drug screen relative to my ability to complete the program, subsequent periodic physical examinations, and be photographed as a condition of enrollment. I understand that I will be bound on all student rules, regulations, and other requirements if I am accepted for enrollment. In the event that I leave, I agree to return all school and/or hospital property issued to me.

Students successfully completing their training are awarded a diploma from the school and are eligible to apply for admission to the certification exam administered by the American Registry of Radiologic Technologists (ARRT). Conviction of a crime including a felony or misdemeanor may impact the candidates’ eligibility to take the ARRT examination. The ARRT will evaluate a candidate’s eligibility status prior to program admission. Contact the program office for further information.

Once this form is submitted you will receive a confirmation page which you must send, along with a $25.00 non-refundable application fee (payable to The Washington Hospital), to:

The Washington Hospital
Radiologic Technology Program
155 Wilson Avenue
Washington, PA 15301