NATIONAL PARK COLLEGE
RADIOLOGIC TECHNOLOGY PROGRAM APPLICATION FORM
Applications are accepted January- April 15
th
Date of Birth: NPC ID:
Print Name Full:
Last Name First Name Middle Name
Cell Phone: Home Telephone:
Mailing Address:
Number & Street City State Zip Code
Social Security: Are you a U.S. Citizen? Yes No
High School:
School Name City State
Date of High School Graduation: Month: Year: G.E.D. Certification: Yes No
Email Address:
List information concerning college, university, or other schools attended:
Name of Institution City & State Dates (From - To) Degree Received
List Work Experience:
Employer Location Dates (From - To) Description of Work
Are all of your transcripts on file at NPC? Yes No Have you applied to NPC? Yes No
Have you previously applied to this Radiologic Technology program? Yes No Date:
Hav
e you
enrolled in a Radiologic Technology program previously? Yes No
If yes, date and institution:
How did you hear about this program?
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY: Between 8:00 a.m. - 4:00 p.m.
Name:
Last Name First Name
Relationship:
Cell
Phone: Work Phone:
(Please complete page 2)
Y:\ NURSING\ SECRETARY_FOLDER\ AccessibleDocuments\ RAD\ RAD_application_NPC 2019_2020.docx (Revised 19)
Are you applying to more than one health science/ nursing program? Yes No
If yes, how many? (Ex: if you are applying to the NPC RAD and another NPC program, count this as 2)
This information does not influence your admission status. It serves to provide information regarding the number of students interested in
pursuing a degree in health science or nursing.
Because a person can find it difficult, if not impossible, to be eligible for the American Registry for Radiologic Technologists
(ARRT) examination to practice as a Registered Radiologic Technologist, please answer the following questions:
1. Have you ever
been convicted of a felony or a misdemeanor? Yes No
2. Do you have a felony charge pending? Yes No
If yes on either of the previous questions, submit an explanation of the felony or misdemeanor, including dates and specific
details. Place it in a sealed envelope addressed to the Dean of Nursing and Health Sciences and attach it to this application.
3. Have you ever been suspended, dismissed or expelled from an educational program for a reason that might affect ARRT
certification requirements?
Yes
No
4. Have you ever had any license registration or certificate denied, revok
ed, suspended, placed on probation or subjected
to
discipline
by
a
regulatory authority or certification board (other than AART)?
Ye
s
No
If you answered yes on any of these question, you must contact the ARRT for a pre-application review of eligibility. Contact
ARRT at 651-687-0048 or www.arrt.org. The ARRT states you mustbe a person of good moral character and must not have
engaged in c
onduct that is inconsistent with the ARRT rules of ethics”. You will not be eligible to apply for this program
without proper documentation from the ARRT.
ON A SEPARATE SHEET OF PAPER PLEASE ANSWER THE FOLLOWING QUESTIONS:
1. Explain your reasons for choosing Radiologic Technology as a career.
2. The Radiologic Technology program is very time intensive. What plans have you made to prepare to meet this
schedule?
3. What are your plans and aspirations for the future?
IMPORTANT INFORMATION:
Please save the completed copy of this application and print. To finalize this application, submit a signed
hard copy to the Division of Nursing & Health Sciences
Refer to the NPC website or the NPC catalog for the essential functions and/or technical standards required for each Nursing
and Allied Health program before submission of this application. National Park College provides academic accommodations as
mandated by ADA and 504. Please contact NPC’s Compliance officer at 760-4227 for reasonable accommodations under the
American’s with Disabilities Act (ADA) and for disability assistance information.
Falsifying any records pertinent to this application can lead to ineligibility or immediate dismissal from the Radiologic Technology
Program. I understand that falsifying my application is dishonest and demonstrates a lack of integrity which could compromise
my acceptance and/or licensure. (PLEASE INITIAL)
I understand the health care industry requires a criminal background check and drug screening upon employment and random
drug testing throughout employment. I also understand that a criminal background check will be required at the time of
admission to the program. I understand that the Substance Abuse Policy of NPC Radiologic Technology Program may require
drug testing during my enrollment for the following reasons: 1) Upon admission into the program. 2) Scheduled testing at
unannounced times throughout the program. 3) Random testing as required by the clinical agencies. 4) For cause.
Signature: Date:
National Park College in compliance with Title VI of the Civil Rights Act of 1964 and Title IX of the Education Amendments of 1972 Higher Education Act does not
discriminate on the basis of race, color, national origin, sex, or qualified handicap in any of its policies, practices, or procedures. The provision includes, but is
not limited to, admissions, employment, financial aid, and other educational services. Any person having inquiries concerning NPC compliance with Title IX is
directed to contact the Dean of Students Office on the second floor of the Student Commons or by telephoning (501) 760-4229.
Return the Complete Application and all documents to:
Nursing & Health Sciences Division- Frederick Dierks
Radiologic Technology Program Director
101 College Drive: Hot Springs, AR 71913
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