School of Radiologic Technology - Regional West Medical Center

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Application Form - there is no application fee Personal Data: __________________________________________________ ________________________________________ Name Phone (including area code) ______________________________________________________________________________________________ Present address (Street) (City, state & zip code) _______________________________________________________________________________________________ Permanent address (Street) (City, state & zip code) ____________________________ _______________________________ ________________________________ E-mail address Permanent phone Cell phone Educational Data: Last high school attended _______________________________________________________________________________________________ Name of high school _______________________________________________________________________________________________ Address (Street) (City, state & zip code) Date completed high school diploma or GED equivalency: _______________ Colleges attended: Number of semesters attended: Year: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Application form (page 1 of 5) 62
Date of graduation: _________________________ Degree _________________________________ Work Experience: Previous experience in health field: __________________________________________________________________________________________________ __________________________________________________________________________________________________ References: __________________________________________________________________________________________________ Name Mailing address __________________________________________________________________________________________________ Name Mailing address __________________________________________________________________________________________________ Name Mailing address __________________________________________________________________________________________________ Name Mailing address I hereby certify that the above information is true to the best of my knowledge. _______________________________________________ Signature Date ___________________ Application form (page 2 of 5) 63
Page 1 and 2:
In-Design Transperancy School of Ra
Page 3 and 4:
School Calendar August 10. ........
Page 5 and 6:
History History of Sponsoring Organ
Page 7 and 8:
Regional West Health Services Missi
Page 9 and 10:
Program Director of Private Postsec
Page 11 and 12: Clinical Educational Settings Educa
Page 13 and 14: Box Butte General Hospital, Allianc
Page 15 and 16: Application Information STUDENT SER
Page 17 and 18: Psychomotor Requirements - The appl
Page 19 and 20: • Latex exposure history 11. Cand
Page 21 and 22: The Program requires students in th
Page 23 and 24: will write a recommendation regardi
Page 25 and 26: application in the application proc
Page 27 and 28: discontinues the program any time a
Page 29 and 30: Aid for academic institution where
Page 31 and 32: 240 Radiation Physics I This introd
Page 33 and 34: Academic Policies mammography, nucl
Page 35 and 36: Fabrication Fabrication can be defi
Page 37 and 38: Clinical Setting Expectations While
Page 39 and 40: cards. Students shall not clock in
Page 41 and 42: Vacation days must be requested in
Page 43 and 44: program, the student will need to a
Page 45 and 46: imaging procedure on a patient with
Page 47 and 48: Graduation To be eligible for gradu
Page 49 and 50: to the effect that the possible dan
Page 51 and 52: feels he or she cannot go to the Di
Page 53 and 54: productivity and/or behaviors must
Page 55 and 56: Services and Activities expectation
Page 57 and 58: Committee regarding the effect on t
Page 59 and 60: of the NSRT board meetings. Student
Page 61: Observation Form To the Technologis
Page 65 and 66: • Ability to communicate proficie
Page 67 and 68: Regional West Medical Center School
Page 69 and 70: Please indicate your opinion of thi
Page 71 and 72: Regional West Medical Center School
Page 73 and 74: Notes _____________________________
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School of Radiologic Technology - Regional West Medical Center

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