Fillable Delgado Community College - Radiation Therapy Admission Application Form

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Delgado Community College - Radiation Therapy Admission Application Form

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RADIATION THERAPY POST-ASSOCIATE DEGREE PROGRAM
ADMISSION APPLICATION FORM
DELGADO COMMUNITY COLLEGE IS AN EQUAL OPPORTUNITY FACILITY. DELGADO COMMUNITY COLLEGE
DOES NOT DESCRIMINATE ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, GENDER, AGE OR
QUALIFIED DISABILITY. SUCCESSFUL ENTRY AS A STUDENT IN THE PROGRAM OF RADIATION THERAPY
WILL BE BASED UPON THE MERITS OF PAST EDUCATION, EXPERIENCE, REFERENCES, RESPONSES TO THE
QUESTIONS ON THE APPLICATION FORM AND POSSIBLE WRITTEN INTERVIEW.
Use ball point pen or typewriter. Illegible or incomplete applications will be returned for revision.
It is recommended that you make a copy of this application for your records.
PERSONAL DATA:
1. Social Security Number: _______________________________ CW ID(LOLA)# _________________________________
2. Full Legal Name: ____________________________________________________________________________________
Last First MI
3. Permanent Home Address:
______________________________________________ __________________________ ______________________
Number & Street Home Phone (Area Code and Number) Cell Phone
__________________________________________________________ ________________________________________________________________
City State Zip E-Mail Address
4. Current mailing address if different from permanent address:
_________________________________________________________
Number & Street
_________________________________________________________ __________________________________________
City State Zip Area Code and Phone Number
5. Emergency Information:
_____________________________________________________________________________________________________________________________
Person to Contact Relationship Area Code and Phone Number
EDUCATIONAL DATA:
6.
List all high schools, trade or vocational schools (use separate sheet if necessary)
Name of School Location Grade Entered Grade Completed Graduated
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
7. List all colleges and universities you have attended (use separate sheet if necessary)
Name Location Major Dates Attended Degree
__________________________________________________________________________FROM_______TO_______ ________________________
Mo/Yr Mo/Yr
__________________________________________________________________________FROM_______TO_______ ________________________
Mo/Yr Mo/Yr
__________________________________________________________________________FROM_______TO_______ ________________________
Mo/Yr Mo/Yr
8. Are you presently enrolled in college? Yes_______ No_______ Semester_________ Institution_______________________________________________
List courses you are taking this semester.___________________________________________________________________________________________
____________________________________________________________________________________________________________________________
For classes starting in January (spring), the deadline is October 1st. When classes begin in August (fall), the deadline is May 1st.
For more information, please contact the Program Director, Robin Wegener at 504-671-6230 or rwegen@dcc.edu
EMPLOYMENT DATA:
9. List your relevant employment experiences over the past 10 years, including military service. Add additional sheet if necessary.
1. ________________________________________________________________________FROM_______TO_______ ________________________
Mo/Yr Mo/Yr
2. ________________________________________________________________________FROM_______TO_______ ________________________
Mo/Yr Mo/Yr
3. ________________________________________________________________________FROM_______TO_______ ________________________
Mo/Yr Mo/Yr
10. Are you reapplying for this program? Yes_____ No _____. If yes, when did you last apply?__________________________________________________
11. Are you a veteran of the US Military Service? Yes _____ No _____. If YES, are you eligible for and certified by the Veterans Administration for education
benefits? Yes _____ No _____ If YES, attach page to this application and give branch of service, dates entered and separated from service, rank at time of
separation and type of discharge.
12. Are you a member of the National Guard or Reserve? Yes_____ No _____. If YES, attach page to application and give branch, days and number of meetings
attended each month.
13. Have you ever been suspended or dismissed from any college or university for scholastic or disciplinary reasons? Yes_____ No_____. If YES, give name of
institution, date and reason for this action. ___________________________________________________________________________________________
14. Have you applied for admission to other Allied Health Programs at Delgado? Yes_____ No_____. If YES, give the program name and dates.
_____________________________________________________________________________________________________________________________
15. Are you a U.S. Citizen? Yes_____ No _____.
16. Optional Response: If you have a disability, describe on a separate page any special equipment, architectural modifications, or other factors which would have to
be considered by you and by the School/department in planning your educational experience at Delgado Community College if you are accepted for admission.
ALL APPLICANTS PLEASE READ CAREFULLY AND SIGN THE FOLLOWING
Other than a minor traffic violation, have you ever been convicted of a felony? Yes_______ No _______ If yes, please explain on additional page.
I UNDERSTAND THAT THE INFORMATION SUBMITTED ON THIS APPLICATION FOR ADMISSION TO DELGADO COMMUNITY COLLEGE’S ALLIED
HEALTH PROGRAM IN MY NAME WILL BE RELIED UPON BY DELGADO COMMUNITY COLLEGE OFFICIALS TO DETERMINE MY STATUS FOR
ADMISSION ELIGIBILITY. I AUTHORIZE DELGADO COMMUNITY COLLEGE OFFICIALS TO VERIFY ANY INFORMATION I HAVE PROVIDED. I
FURTHER AUTHORIZE ANY AND ALL EDUCATIONAL INSTITUTIONS, GOVERNMENTAL AGENCIES, AND PRIVATE EMPLOYERS THAT I HAVE
ATTENDED, WORKED FOR, OR WHO MAINTAIN RECORDS RELATED TO ME TO RELEASE SUCH INFORMATION TO DELGADO COMMUNITY
COLLEGE.
I AGREE TO NOTIFY DELGADO COMMUNITY COLLEGE’S ALLIED HEALTH ADMISSIONS OFFICE OF ANY CHANGES TO THE INFORMATION
PROVIDED.
I CERTIFY THAT THE INFORMATION IN THIS APPLICATION IS COMPLETE AND CORRECT AND UNDERSTAND THAT SUBMISSION OF FALSE,
INCOMPLETE, OR INCORRECT INFORMATION IS GROUNDS FOR REJECTION OF MY APPLICATION, WITHDRAWAL OF ANY ACCEPTANCE OFFER,
CANCELLATION OF ENROLLMENT, OR APPROPRIATE DISCIPLINARY ACTION. I UNDERSTAND IT IS ALSO NECESSARY TO COMFORM TO THE
PROGRAM’S TECHNICAL STANDARDS AND REQUIREMENTS CONCERNING A PHYSICAL EXAMINATION.
IF ACCEPTED, I AGREE TO ABIDE BY AND
OBSERVE ALL PROGRAM AND AFFILIATE HOSPITAL POLICIES, RULES AND REGULATIONS, AS AMENDED FROM TIME TO TIME.
I ALSO UNDERSTAND THAT THIS APPLICATION IS FOR THIS PROGRAM ONLY. IF I ENTER DELGADO COLLEGE, I MUST FILL OUT AND SUBMIT
A DELGADO COLLEGE APPLICATION FOR ADMISSION. COMPLETION OF THIS FORM DOES NOT INDICATE THAT YOU ARE ACCEPTED INTO
THE PROGRAM.
___________________________________________________________________ ______________________________________
Signature of Applicant Date
For classes starting in January (spring), the deadline is October 1st. When classes begin in August (fall), the deadline is May 1st.
For more information, please contact the Program Director, Robin Wegener at 504-671-6230 or rwegen@dcc.edu
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Delgado Community College - Radiation Therapy Admission Application Form

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Completed 28 April 2020

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