Radiologic Science Program

Radiologic Science Program - Application

Darton College of Health Professions at ASU West

2400 Gillionville Road

Albany, GA 31707-3098

Directions

Please complete this entire form and submit it along with other forms and related documents to be evaluated for admission to the program office by NOVEMBER 1st. If accepted, the applicant will begin occupational (RADS) courses the following January. It is the applicant’s responsibility to make sure all forms are fully completed and submitted to the program by the deadline.

Contact Information

Last Name:*

First Name:*

Middle Initial:

Student ID#:

(Optional)

Address:*

City:*

State:*

Select

Zip:*

Phone:*

Phone

Alternate Phone:*

Phone

Email:*

Emergency Contact Information

Emergency Contact Name:*

Please type in the First and Last Name

Relation:*

Emergency Contact Phone:*

REQUIRED Documents:

The documents listed below are REQUIRED to complete your application:

Transcripts: Official (I have had all of my transcripts sent to ASU’s Office of Admissions) or Unofficial (Attached and Uploaded to this application).

TEAS Score Report (I have scored at least 50 on the TEAS).

Transcripts (Official / Unofficial)?*

TEAS Score Report?*

OPTIONAL Documents:

The documents listed below are OPTIONAL to UPLOAD and SUBMIT with your application:

• Certification of Medical Examination Form.

• Certificate of Immunization Form.

• Recommendation Forms (Must provide at least three).

a. I am returning the forms in sealed envelopes myself, OR

b. I will upload them with this application.

• Volunteer Documentation (for additional points).

Please use the list below to select which OPTIONAL documents you will UPLOAD and SUBMIT:

Certification of Medical Examination Form?

Certificate of Immunization Form?

Volunteer Documentation (for additional points)?

Recommendation Forms (Must provide at least three)?

I am returning these in sealed, authenticated envelopes

Sent directly from the evaluator to program

File Upload*

PLEASE USE THIS SECTION TO UPLOAD ANY REQUIRED AND/OR OPTIONAL DOCUMENTS:

Drag and drop files here or

Signature

Please read the following statement and sign confirming agreement to the statement.

Statement:*

I have read and understand the Radiologic Science program application requirements and selection process explained in the application packet. I understand and will follow any requirements set forth by the Radiologic Science program. I will provide all health documentation outlined in this application packet prior to beginning clinical assignments. I am aware of the job market and employment outlook both locally and nationally for this profession. I am aware of the physical requirements of the program.

Yes

Signature:*

Please type in your First and Last Name

Date:*

Mandatory Student Health Insurance

Albany State University – Darton College of Health Professions

Radiologic Science Program

Beginning Fall Semester 2014, all new students accepted into ANY Health Sciences or Nursing Program at Albany State University will be required to show proof of active Medical Insurance coverage. This is a Board of Regents of the University System of Georgia mandate, and not an ASU mandate. Proof of coverage must be submitted designated dates at the beginning of each spring semester. Submissions CANNOT be done BEFORE or AFTER these designated dates. Submission is done via the Albany State University website.

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

Through a currently active parent plan.

Through a currently active individual or family plan.

Through a currently active Employer-Sponsored plan.

Through a currently active Albany State University Student Health

Insurance Plan (SHIP).

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 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 Albany State University Health Sciences or Nursing Program requires Mandatory Medical Insurance coverage.

Student Signature:*

Please type in your First and Last Name.

Date:*

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:*

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