Medical Laboratory Technology Program - Application

Albany State University - West Campus

MLT Program

Darton College of Health Professions

2400 Gillionville Road

Albany, GA 31707-3098

Telephone 229-500-2238

Fax 229-500-4393

Contact Information

NOTE: If you do not have an ASU student ID#,

you are not eligible to participate in this Program.

Last Name:

First Name:

Middle Initial:

Today's Date:

mm/dd/yyyy

Albany State University Student ID#:

(Optional)

(ex. 900xxxxxx)

DOB:

mm/dd/yyyy

Current Mailing Address:

City:

State:

Zip:

Primary Contact Number:

Phone

Personal Email:

Program Option

Check Program Option:

Online (requires clinical support)

Hybrid (online courses/on campus labs)

Education / Experience

List colleges previously attended and degrees held:

1) College/University Name:

Date (Start):

mm/dd/yyyy

Date (End):

mm/dd/yyyy

Degree Awarded:

2) College/University Name:

Date (Start):

mm/dd/yyyy

Date (End):

mm/dd/yyyy

Degree Awarded:

3) College/University Name:

Date (Start):

mm/dd/yyyy

Date (End):

mm/dd/yyyy

Degree Awarded:

Have you previously applied to this program?

Yes

Have you applied to another Health Sciences Program?

Yes

Is Medical Laboratory Technology your current major?

Yes

Signature

I have read all of the attached information and understand the application and selection process.

I hereby apply for admission to the Albany State University Medical Laboratory Technology Program for the Fall Semester of the year listed below:

Semester

Fall Semester

Signature:

Please type in your First and Last Name.

Date:

mm/dd/yyyy

Mandatory Student Health Insurance

Beginning Fall Semester 2014, all new students accepted into ANY Darton College of Health Professions will be required to show proof of active Medical Insurance coverage. This is a new Board of Regents of the University System of Georgia mandate, and not an Albany State University mandate. Proof of coverage must be submitted between August 1 and September 5 or as otherwise posted. Submissions CANNOT be done BEFORE August 1, or AFTER September 5. Submission is done via the following website only:

Click here for more information regarding student health insurance

Proof of coverage must be provided in one of the following ways:

1) Through a currently active parent plan.

2) Through a currently active individual or family plan.

3) Through a currently active Employer-Sponsored plan.

4) Through a currently active Albany State University Student Health Insurance Plan (SHIP).

5) Through a currently active Government-Sponsored Plan.

If a student fails to provide appropriate proof of coverage during the dates stated above, the student will be automatically enrolled (via the Business Office) into plan #4 above. As of May 1, 2014, the Annual Premium rate for Plan #4 was as follows:

Student – Age 26 and Under $1,381.00

Student – Age 27 and Older $1,782.00

*These rates and dates are subject to change without notice.

Additionally, Health Insurance coverage must be maintained by the student throughout the entire time that he/she remains enrolled and is actively progressing through his/her respective Health Sciences or Nursing Program. If a student fails to maintain Health Insurance coverage, then he/she will be immediately dismissed from his/her respective Health Sciences or Nursing Program for failure to maintain the mandatory coverage as required by the Board of Regents of the University System of Georgia. If you have any questions regarding this requirement, please contact your respective Program Director, the Health Sciences Division Office, or the Nursing Division Office.

I have read the above statement, and I understand the requirements as listed above and understand that my acceptance into any Darton College of Health Professions requires Mandatory Medical Insurance coverage.

Student Signature:

Please type in your First and Last Name.

Date:

mm/dd/yyyy

Required Documents Upload

PLEASE USE THIS SECTION TO ATTACH THE FOLLOWING REQUIRED DOCUMENTS:

1. Immunizations Records: includes HBV x3, Varicella x2, MMR x2

2. Letters of Recommendation (three)

3. Physical Exam Record

4. Course Plan

5. Clinical Support Documentation (for ONLINE Students)

File Upload

Drop your files here

Immunizations Records: includes HBV x3, Varicella x2, MMR x2?

Letters of Recommendation (three)?

Physical Exam Record?

Course Plan?

Personal Identifiable Information (PII) Notice:

All personal data and special categories of sensitive personal data collected or processed by Albany State University (ASU) must comply with the ASU Cybersecurity Program Plan, as authorized by the Board of Regents Policy Manual Section 10.4 Cybersecurity:

https://www.usg.edu/policies

Anyone suspecting his or her sensitive personal data has been exposed to unauthorized access, report your suspicion to:

LegalAffairs@asurams.edu

Otherwise, questions concerning GDPR can be forwarded to LegalAffairs@asurams.edu. Typing your name in the box below and submission of this application provides consent to and acknowledgment of the ASU Data Security and Privacy Policy.

Personal Identifiable Information (PII) Consent:

Please check the box below to indicate that you have read and understood the PII policy above.

Personal Identifiable Information (PII) Consent:

Send me a copy of my responses

Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.