Admission Application for Radiography Program "*" indicates required fields I. PERSONAL DATAFirst Name* First Name Middle Name Last Name Student ID* Your E-mail address* Phone*Cell Number*Address* Address City State / Province / Region ZIP / Postal Code Do you have a valid NJ driver’s License?* Yes No Will you have access to a car during the school year?* Yes No Are you presently employed?* Yes No Employed Type* Full Time Part Time Are you financially able to attend school for 24 months without working full-time?* Yes No Do you have Health Insurance:* Yes No NOTE: You MUST have health insurance before starting the program, no exceptions. The college does NOT offer health insurance.Have you taken the Tests of Essential Academic Skills (TEAS)?* Yes No Date* MM slash DD slash YYYY Test of Essential Academic Skills (TEAS) score* Emergency ContactEmergency Full Name* Address Address City State / Province ZIP / Postal Code II. EDUCATION AND EMPLOYMENT RECORDDid you attend High School?* Yes No Did you you Graduate?* Yes No High School Name* Favorite Subject Least favorite subject Subject(s) you did well in Graduation Date MM slash DD slash YYYY Do you have a GED?* Yes No Favorite Subject Least favorite subject Subject(s) you did well in Date of GED* MM slash DD slash YYYY Did you attend College?* Yes No Previous College Name Major* Years Attended* Reason for leaving* How many semesters of each of the following subjects did you have in high school or at a previous college?Math*Please enter a number from 0 to 10.Physics*Please enter a number from 0 to 10.Gen. Science*Please enter a number from 0 to 10.Chemistry*Please enter a number from 0 to 10.Biology*Please enter a number from 0 to 10.Did you take the placement test?* Yes No Basic Skills Placement Test Scores*Basic Skills Placement Test Date* MM slash DD slash YYYY Healthcare Related Employment*Other Work Experience*III. COURSES YOU HAVE ALREADY COMPLETED (please check all that applies)COURSES YOU HAVE ALREADY COMPLETED (please check all that applies)* BS 103 Anatomy & Physiology I EN 101 Composition I PS 101 Intro to Psychology CH 103 Intro to Chemistry BS 104 Anatomy & Physiology II EN 102 Composition II CIS 101 Computer Concepts & Application MA 108 College Algebra 3 credits in Humanities Course taken (If you checked, 3 Credits in Humanities)* By checking this box, I certify that information provided on this form is true and correct, to the best of my knowledge.* By checking this box, I certify that information provided on this form is true and correct, to the best of my knowledge. Student SignatureStudent's Signature Date* MM slash DD slash YYYY REVIEWER’S SECTION (Office use only)Reviewer*Reviewer's Signature Date MM slash DD slash YYYY
