Fillable Radiologic Technology Program Application Checklist Please use this (Jackson State Community College)

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Radiologic Technology Program Application Checklist Please use this (Jackson State Community College)

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Radiologic Technology Program
Application Checklist
Please use this form as a reference so that all items required are attached with your program
application when submitted. ALL application materials must be received in the Health
Sciences Dept. or postmarked by the June 1
st
deadline. NO FAXED or EMAILED
applications are accepted!
ALL APPLICANTS MUST:
Meet admission requirements for Jackson State Community College
Are you a new JSCC student? Have you ever taken classes at JSCC? Have you completed the
JSCC college application? If you have questions about your college admissions status, please
contact the Admissions Office.
Are you a continuing JSCC student? Have you taken classes within the last semester or so? If you
have, then you should have met the college admissions requirements.
ALL APPLICANTS MUST:
Successfully complete all requirements of the Radiologic Technology Program Application
**** Students applying with college experience (at least 11 college level credit hours)****
Have you completed and printed the program application including a current email address along
with indicating both first and second choice of clinical affiliations?
Have you attached a one page essay outlining personal and professional goals?
Have you attached a COPY of college/university transcripts from ALL institutions attended
INCLUDING JSCC?
** First-time college students (applying with no college credit or less than 11 college level credit hours)**
Have you completed and printed the program application including a current email address along
with indicating both first and second choice of clinical affiliations?
Have you attached a one page essay outlining personal and professional goals?
Have you attached a COPY of high school transcripts AND all ACT scores?
Mail materials to: Jackson State Community College, ATTN: Health Sciences Department c/o
Radiography Program Application, 2046 North Parkway, Jackson, TN 38301-3797, or deliver in
person to the Health Sciences Department or Radiological Technology Program faculty/director.
After submitting or mailing program application packet to the Health Sciences Department by
June 1st, PLEASE frequently check the email address you listed on the application for
information concerning admission/interview status. We will be using your application email to
contact you!!!
RADIOLOGIC TECHNOLOGY PROGRAM
APPLICATION FOR ADMISSION
Applicants MUST include copies of ALL college transcripts OR copies of high school transcripts/ACT scores
All applicants must include an essay with this application
PERSONAL INFORMATION (PRINT or TYPE) APPLICATION DEADLINE: June 1
EDUCATIONAL INFORMATION
MEDICAL EXPERIENCE
CLINICAL EDUCATION CENTER (indicate preference of clinical site by numbering 1-4, with 1 being first choice, etc.)
Jackson State Community College, a Tennessee Board of Regents institution, does not discriminate on the basis of race, color, national origin, gender, religion,
age, or disability in educational services. 2019
Name: ________________________________________________ Date: __________________
Address: ___________________________________________________ Phone: ( )____________________
City: _______________________________________________ State: _________ Zip: _________________
Current email address that you check frequently: ____________________________________________________
For applicants applying with recent High School Graduation, GED, no college credit, or High School Graduate
w/Dual Credit
High School Graduation Date: __________________________________ GPA: ______________________
GED Date:______________________________________ Score: _____________________
ACT Scores
English __________, Math ___________, Science __________, Reading _________, Composite ____________
Dates of ACT Exam: _________________________________________________________________________
For applicants applying with at least 11 hours of college/university level credit and a minimum GPA of 2.5
Provide a complete list of all institutions attended on separate page if too many to list here (include JSCC if applicable)
College_____________________________________________ Dates and GPA _______________________
College_____________________________________________ Dates and GPA _______________________
College ____________________________________________ Dates and GPA _______________________
Medical Experience: Employment ___ Volunteer work ___ Observation in radiology ___
Facility_______________________________________________ Position______________________________
City/State______________________________________________ Dates _____________ to ________________
___________Jackson-Madison Co. General Hospital/North Campus _________ WTH Dyersburg Hospital
__________ Baptist Memorial Hospital - Union City ________Henry County Medical Center - Paris
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Completed 27 July 2020

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