Limited Permit X-ray Technician Bone Densitometry School ID#6020 ...

School information
Date: , 2013
Time: Friday 7:30 am – 7:30 pm
Saturday and Sunday 7:30 am – 8 pm - Each student’s schedule varies
Location: 1814 Franklin Street, Suite 620 Oakland, CA 94612
Meals: A light breakfast and lunch is provided each day and dinner is provided on Friday.
Capacity: We accept the first 12 applications.
State requirements that you will receive
Fees*
1. Eighteen (18) hours of formal classroom education including:
3 hours on radiation physics, biology, and protection
3 hours on bone biology, bone disease and therapy, and densitometry parameters
4 hours on X-ray bone densitometry equipment
3 hours of computers and image formation
4 hours on anatomy and patient positioning
1 hour on ethics and patient handling
2. Four (4) hours of laboratory training where you will use phantoms and evaluate images.
3. Four (4) hours of supervised clinical education where you will do radiographic procedures:
5 scans of the posterior/anterior spine
5 scans of the hip
10 scans of a variety of extremities
Non-Refundable registration fee $100.00
Tuition $1,520.00
State license application fee $75.00
Total tuition and fees $1,695.00
*All tuition and applicable fees are due at the time of registration.
To apply, complete and return
Registration Form (signature required in three places)
Performance Fact Sheet
Cancellation and Refund Policy
Admission Questionnaire and attachments as required
Limited Permit X-ray Technician
Bone Densitometry
School ID#6020
CLASS NOTIFICATION
If you have any questions about the school, please call @ (510) 832-2663 x22
Class Notification Only – Application begins on the next page.
Page 1

Please complete and mail, fax, or email back to: FORE
1814 Franklin Street, Suite 620
Oakland, CA 94612
Fax: (510) 208-7174
Email: education@fore.org
Student Information
_________________________________________ ______________________________________
Last Name First Name
____________________________________________________________________________________
Address City State Zip
___________________________________ ____________________________________
Email Date of birth (required)
___________________________________ ____________________________________
Daytime phone Fax number
___________________________________
Current occupation
Do you have access to a DXA Machine? No Yes – Manufacturer___________________
Fees*
Non-Refundable registration fee $100.00
Tuition $1,520.00
State license application fee $75.00
Total tuition and fees $1,695.00
*All tuition and applicable fees are due at the time of registration.
Limited Permit X-ray Technician
Bone Densitometry
School ID#6020
REGISTRATION FORM Page 1 of 3
Payment** Check enclosed for $_________
Credit Card _______________________ Expiration Date _________________
** In order to pay for your tuition by a check, we are required a credit card number on file. Your credit card will not be charged
without notifying you.
VISA MasterCard AMEX Discover
__________________________________ ____________________________________________
Name as it appears on Card Card Holder’s Signature
__________________________________ _____________________________________________
Card Number Expiration Date
Page 2

This registration will not become operative until you attend the first day of
instruction.
Location FORE
1814 Franklin Street, 9 th Floor Conference Room
Oakland, CA 94612
(510) 832-2663 x22
Name Limited Permit X-ray Technician: Bone Densitometry
Date May 10-12, 2013
Fee $1,695.00
FORE is registered with the State of California. Registration means we have met certain
minimum standards imposed by the state for registered schools on the basis of our written
application to the state. Registration does not mean we have met all of the more extensive
standards required by the state for schools that are approved to operate or licensed or that the
state has verified the information we submitted with our registration form.
CANCELLATION AND REFUND POLICY
Limited Permit X-ray Technician
Bone Densitometry
School ID#6020
REGISTRATION FORM Page 2 of 3
FORE shall refund for all students, without penalty or obligation, the total tuition and fees less the
non-refundable registration fee of $100, if notice of cancellation is made 10 business days prior to
the first day of instruction. Any cancellation made within 10 days of the first day of instruction
forfeits 50% of the tuition charges plus the non-refundable registration fee. Should the student
withdraw and complete 60 percent or less of the course the student will receive a pro rata refund.
The amount owed by the student for the purpose of calculating a refund is derived by multiplying
the total hours attended by the hourly charge of $60.54 for instruction, plus the non-refundable
registration fee of $100. The refund shall be any amount of excess as shown on the following
page. Any notification of the withdrawal or cancellation and any request for a refund is a required
to be in writing.
FORE shall pay for credit refunds due on a reasonable or timely basis, not to exceed 30 days
following the date upon which the student’s withdrawal has been determined.
Page 3

Examples of the application of the cancellation and refund policy
Non-Refundable
Registration Fee
Cancellation prior
to 10 days
of the first day of
instruction
Cancellation 10
days or less than
the first day of
instruction
You forfeit 50%
of tuition
Cancellation after
8 hours of
instruction
You forfeit 50%
of tuition plus the
hourly rate
Cancellation after
10 hours of
instruction
You forfeit 50%
of tuition plus the
hourly rate
$100.00 $100.00 $100.00 $100.00
Tuition Charge $1,520.00 $1,520.00 $1,520.00 $1,520.00
Less Instructional
Charge of $60.54 / hour
$0.00 $0.00 $484.32 $605.40
State Application Fee $75.00 $75.00 $75.00 $75.00
Refund Due* $1,595.00 $835.00 $350.68 $229.60
This is a legally binding agreement when signed by you and accepted by FORE.
Any cancellation made within 10 days of the first day of instruction forfeits 50% of the tuition
charges plus the non-refundable registration fee.
Print Student Name Date
Signature
Limited Permit X-ray Technician
Bone Densitometry
School ID#6020
REGISTRATION FORM Page 3 of 3
FORE Program Coordinator Date
Signature
Page 4

THE FORE SCHOOL
The FORE Limited Permit X-Ray Technician School is not an entry-level course. The school is three days
of intensive training. FORE is not able to tell you how many students graduate, how many find jobs, or how
much money a student can earn after finishing this school.
REQUIREMENTS TO PASS
Limited Permit X-ray Technician
Bone Densitometry
School ID#6020
SCHOOL PERFORMANCE FACT SHEET
A Certificate of Completion is required for students to apply to take the State of California Bone
Densitometry Equipment Operator Examination to receive a Limited Permit in X-Ray Bone Densitometry.
To receive a certificate of completion from FORE, students must pass a 60 question written exam with 80%
correct answers AND be deemed competent to perform bone density scans as evaluated by a clinical
instructor.
If a student fails the FORE written exam, they may take a re-test for a fee of $30.00. If a student is not
deemed competent to perform bone density scans, they may return for remedial work for an additional fee
of $285.00.
NOTICE CONCERNING TRANSFERABILITY OF UNITS AT OUR SCHOOL
The certificate of completion you earn at FORE’s Limited Permit X-Ray Technician School will not be
transferable to any college or university. In addition, when you earn a certificate of completion from the
school it will not serve as a basis for obtaining a degree at a college or university.
I understand the school performance fact sheet and agree to all of the
requirements.
_______________________________ __________________________________
Print Student Name Date FORE Program Coordinator Date
_______________________________ __________________________________
Signature Signature
Page 5

This Limited Permit X-Ray Technician School is not entry level, but an
intensive three day training program to prepare you to sit for the State of
California Limited Permit Bone Densitometry Equipment Operator
Examination. To ensure your success, we will review this questionnaire
prior to admitting you to the school. If we believe you may not be a
suitable candidate to successfully pass the coursework, we will contact you.
1. What is your name?
2. What is your current job title?
3. Do you or have you had any experience in the health field? If yes, please explain.
4. Do you have any radiology or imaging experience? If yes, please explain.
5. What is the highest level of education you have completed?*
High School/GED
2-year Associate Degree
4-year Bachelor’s Degree
Masters
PhD or MD
* Please attach proof of completion
6. Please attach the following:
Resume
Anatomy and/or physiology course (unofficial transcript is okay)
Other related course work (please specify):
Limited Permit X-ray Technician
Bone Densitometry
School ID#6020
ADMISSION QUESTIONNAIRE
Page 6