Histologic Technician Program - Application

Albany State University

Histologic Technician Program

Health Sciences Division

Darton College of Health Professions

2400 Gillionville Rd.

Albany, GA 31707

Term

Term/Year you intend to begin:

Fall 2025

Spring 2025

Contact Information

Last Name:

First Name

Middle Initial:

RAM ID:

(Optional)

Mailing Address

City:

State:

Zip:

Home Phone:

Phone

Work Phone:

Phone

Cell Phone:

Phone

Email Address:

Experience / Education

Are you currently working in the field of Histotechnology?

If “Yes,” please complete the Work Experience Form (and not the Laboratory Visitation Form)

Yes

Do you plan to use your work facility to complete the labs/clinical requirements?

Yes

N/A

(Fall entrance only) Are you going to complete the first semester lab requirements at Albany State University?

Yes

N/A

Do you plan to relocate after graduation?

Yes

1) Professional Reference Name:

Professional Reference Phone Number:

2) Professional Reference Name:

Professional Reference Phone Number:

Grade Point Average (must be a minimum of 2.5)

The GPA to include on this page is your choice and may be either your overall cumulative GPA or the GPA for the last 35 hours of earned college credit. Use the Cumulative GPA Form included within this packet to calculate the chosen GPA, and include the completed form with the application. Indicate which GPA has been included by writing in the designated area for which you calculated (i.e., select either Cumulative or Last 35 hours).

Cumulative GPA

Last 35 Hours GPA

PREVIOUS WORK EXPERIENCE

Do you have previous histologic work experience?

If “Yes,” list number of years, location(s) and check competencies in the areas below.

Yes

Demographic Information

*The only use of this information is to submit data for institutional use and will not be considered for acceptance into the program.

Date of Birth (optional):

mm/dd/yyyy

Sex:

Male

Female

How did you learn about the Histologic Technician Program?

Have you previously applied to Albany State University’s HT Program?

Yes

Do you currently have an associate’s or higher-level degree?

If “Yes,” please provide proof with application (e.g., transcript that shows degree awarded, copy of diploma)

Yes

Route of program completion:

AASD

Certificate

Acknowledgement / Signature

Acknowledgement

I hereby apply for admission to the HT Program for Fall / Spring Semester listed above and certify this application is both correct and complete. I have read the application packet, including the essential abilities required and understand the application and selection criteria and that the class size is limited to 20 students for the fall semester and 10 students for the spring semester.

I further understand that any failure on my part to comply with these processes will result in my application not being reviewed. I understand that meeting all minimum requirements does not guarantee admission into the program.

Yes

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. All applicable transcripts (unofficial copies will suffice)*

2. Two letters of recommendation (via the Applicant Recommendation

Form)

3. Completed Physical Evaluation Form

4. Completed Clinical Affiliate Information (online students only)

5. Immunization records to include Hepatitis B series (copy of series

verification)*

6. Completed Laboratory Visitation Form, if applicable

7. Completed GPA Calculation Form

8. Florida resident, certificate of proof for training for Florida HIV safety,

Medical Errors & Laws and Rules.

* The transcripts and immunization forms are in addition to the request for these documents by the Office of Admissions.

File Upload

Drop your files here

Unofficial Transcript(s)?

Applicant Recommendation Form (two required)?

Physical Evaluation Form?

Clinical Affiliate Information (online students only)?

Immunization Records?

Laboratory Visitation Form?

GPA Calculation Form?

Florida Resident, Certificate of Proof for Training for Florida HIV Safety, Medical Errors & Laws and Rules?

MANDATORY STUDENT HEALTH INSURANCE ACKNOWLEDGEMENT

Beginning Fall Semester 2014, all new students accepted into ANY Health Sciences or Nursing Program at Albany State University will be required to verify active Medical Insurance coverage. This is a new Board of Regents of the University System of Georgia mandate and not a Albany State University mandate. Proof of coverage must be submitted during a specified time period after acceptance into any Health Sciences or Nursing Program at ASU. Submissions CANNOT be done BEFORE or AFTER the given time period. Submission is done via UnitedHealthcare’s StudentResources webpage.

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 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 their 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.

By signing below, I certify that I have read the above statement and I understand the requirements as listed above and understand that my acceptance into any Albany State University Health Sciences or Nursing Program requires Mandatory Medical Insurance coverage.

Student Signature:

Please type in your First and Last Name.

Date:

mm/dd/yyyy

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

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