NATIONAL PARK COLLEGE
RESPIRATORY THERAPY PROGRAM APPLICATION FORM
Applications are accepted from January 1
st
July 15th
Date of Birth: NPC ID Number:
Print Name in Full:
Last Name First Name Middle Name
Cell Phone: Home Telephone:
Mailing Address:
Number & Street City State Zip Code
Social Security Number: 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 high schools, colleges, or university 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 previously applied to this program?
Yes No Date:
Have you enrolled in a Respiratory Therapy program previously?
Yes No
If yes, date and institut
ion:
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY:
Between 8:00 a.m. - 4:00 p.m.
Name:
Relationship:
Cell Phone:
Work Phone:
(Please complete page 2)
Y:\ NURSING\ SECRETARY_FOLDER\ AccessibleDocuments\ RESP\ RT_application_NPC 2019_2020.docx (Revised 19)
How did you hear about this program?
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 RT 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 OBTAIN A LICENSE TO PRACTICE
AS A RESPIRATORY THERAPIST UNDER CERTAIN CONDITIONS, PLEASE ANSWER THE FOLLOWING
QUESTION:
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 and/ 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.
ON A SEPARATE SHEET OF PAPER PLEASE ANSWER THE FOLLOWING QUESTIONS:
1. Give your reasons for choosing respiratory therapy as a career.
2. The respiratory therapy program is very time intensive. What have you done to prepare to meet this schedule?
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 health sciences
programs. 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 Respiratory Therapy 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
Respiratory Therapy Program Director
101 College Drive: Hot Springs, AR 71913
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