Respiratory Care Program

Respiratory Care Program - Application

Albany State University

2400 Gillionville Rd.

Albany, GA 31707

Contact Information

Date:*

First Name:*

Middle Initial:

Last Name:*

ASU Student ID Number:

(Optional)

Mailing Address:*

Street and Number or P.O. Box

City:*

State:*

Select

Zip:*

Home Phone:*

Work Phone:

If Applicable

Cell Phone:*

Social Security Number:*

Email Address:*

Admission Acknowledgement

I hereby apply for admission to the Albany State University Respiratory Care program for the class beginning in the semester listed below. I have read all of the attached information and understand the application and selection process.

Semester Applying For:*

Summer 2025

Signature:*

Please type in your First and Last Name.

Date:*

Mandatory Student Health Insurance

Beginning Fall Semester 2014, all new students accepted into the Respiratory Care Program at Albany State University will be required to show proof of active Medical Insurance coverage. This is a new mandate by the Board of Regents of the University System of Georgia and Albany State University is required to comply. Proof of coverage must be submitted between August 1, and September 5, each year. Submissions CANNOT be completed BEFORE August 1, or AFTER September 5, 2014 for the Fall Semester. Submission is done via the following website:

Click here to view Health Insurance information.

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 are subject to change without notice.

Additionally, Health Insurance coverage must be maintained by the student throughout the entire time he/she remains enrolled and actively progressing through the Respiratory Care Program. If a student fails to maintain Health Insurance coverage, then he/she will be immediately dismissed from the Respiratory Care 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 the Respiratory Care Program Director, or the Health Sciences Division Office.

I have read the above statement and I understand the requirements as listed above and understand that my acceptance into the Albany State University Respiratory Care Program requires Mandatory Medical Insurance coverage.

Student Signature:*

Please type in your First and Last Name.

Date:*

Financial Responsibility for Accidents

I, (Your Name), acknowledge that I am personally responsible for any health care expenses that may occur as a result of any unfortunate accident, injury, or exposure to any communicable disease that may occur during any class, laboratory, or clinical practicum that is a part of the Respiratory Care Program. This includes any incidents that may occur in the hospital, during patient transports, or during travel with an assigned home care company.

I further agree that Albany State University, or any of the Respiratory Care Program’ s clinical affiliates, will not be held financially responsible for any treatment I may require as a result of such an accident.

Signature:*

Please type in your First and Last Name.

Date:*

Albany State University Respiratory Care Program: Essay

Instructions: This essay is required of all applicants to the respiratory program. The essay must be limited to 250 words. The quality of the essay will be reviewed by the program selection committee and is part of the admission selection process. Neatness, spelling, grammar, and punctuation all count in the scoring process. Students should express thoughts clearly and concisely to meet the length requirement.

TOPIC: How will the Respiratory Therapy Profession satisfy my personal goals during the next five years?*

Student Insurance and Medical Record

Part A: To be completed by student

Health Ins. Co:*

Policy Number:*

Person Insured:*

Please type in the First and Last Name.

Personal Physician:*

Please type in the First and Last Name.

Emergency Contact Name:*

Please type in the First and Last Name.

Emergency Contact Phone Number:*

Phone

Healthcare Employment Questionnaire

1. Have you ever been employed at a healthcare facility to include but not limited to hospital, physician practice, urgent care, nursing home, etc?*

Yes

Facility Name:

If yes, please provide the following

Job Title:

Start Date:

End Date:

Reason for Leaving:

Rehire Status:

Yes

2. May we contact your past employer for a reference?*

Yes

Facility Phone Number:L

If yes, please provide the following contact information.

Phone

Required Documents Upload

PLEASE USE THIS SECTION TO ATTACH THE FOLLOWING REQUIRED DOCUMENTS:

1. Transcripts: Official (I have had all of my transcripts sent to ASU’s Office of Admissions) or Unofficial (Attached and Uploaded to this application) ONLY if you are not currently an ASU student.

2. Certification of Medical Examination Form (Part B: To be completed by a Physician/PA/ARNP).

3. Student Immunization Record.

4. Hospital Visitation Form (Optional).

5. Applicant Recommendation Form (Must provide at least three).

File Upload:*

Drag and drop files here or

Transcripts (Official / Unofficial)?*

Certification of Medical Examination Form (Part B: To be completed by a Physician/PA/ARNP)?*

Student Immunization Record?*

Hospital Visitation Form (Optional)?

Applicant Recommendation Form (Must provide at least three)?*

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.

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

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