APPLICATION FOR ADMISSION TO THE BEAUMONT SCHOOLS OF ALLIED HEALTH

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1 day s Date APPLICATION FOR ADMISSION TO THE BEAUMONT SCHOOLS OF ALLIED HEALTH Start Date of Program Applying 3601 West 13 Mile Road Royal Oak, Michigan Select the one program applying to: L Radiologic Technology L CT L MRI L Nuclear Medicine Technology L Radiation Therapy L Histologic Technician L Histotechnologist L Medical Technology L Polysomnographic Technology L Clinical Oncology Massage Name First Middle Last Soc. Sec. No. Present Address Number Street City State Zip Code Home Phone Daytime Phone # Permanent Address Number Street City State Zip Code Home Phone Daytime Phone # Address Driver s License Number Other name(s), if any, you have used for work or educational records Have you ever been employed by Beaumont or any of its subsidiaries or affiliated companies? Are you a recipient of a Beaumont scholarship or loan? If yes, where? L Royal Oak L Troy L Grosse Pointe Other: Are you currently employed by Beaumont and where? L Royal Oak L Troy L Grosse Pointe Other: Are you registered, certified or licensed by any state and/or national organization? If yes, list organizations Registry, Certification or License No. Serial / Audit No. Expiration Date What prompted you to apply here: L Counselor L Advisor L Former Student L Beaumont website L College posting L Career Day L Presentation by Beaumont Employee L Schools of Allied Health website L Direct mail L Internet ad L Newspaper ad L Billboard L Employee Reference L Job fair L Professional journal L Cable Television L Instructor/ Teacher L Job posting board L Radio L You or someone you know has received services at Beaumont L Other Are you a US Citizen? If you are not a US Citizen, attach all US immigration status documents to this application OS7 Applicant - Turn page and continue

2 EMPLOYMENT BACKGROUND LIST IN ORDER, MOST RECENT POSITION FIRST. If presently employed, may we contact? FIRM NAME TELEPHONE L Contingent L Full Time L Part Time DUTIES AND RESPONSIBILITIES ADDRESS DATES STARTING POSITION FINAL POSITION SUPERVISOR REASON FOR LEAVING FIRM NAME TELEPHONE L Contingent L Full Time L Part Time DUTIES AND RESPONSIBILITIES ADDRESS DATES STARTING POSITION FINAL POSITION SUPERVISOR REASON FOR LEAVING FIRM NAME TELEPHONE L Contingent L Full Time L Part Time DUTIES AND RESPONSIBILITIES ADDRESS DATES STARTING POSITION FINAL POSITION SUPERVISOR REASON FOR LEAVING Health care related experience / volunteerism DATES: OS7

3 EDUCATIONAL BACKGROUND SCHOOL NAME AND ADDRESS OF SCHOOL COURSE OF STUDY DATES High School DID YOU GRADUATE? LIST DIPLOMA OR DEGREE AND DATE Trade or Business School College #1 College #2 College #3 If there are additional colleges/universitites attended, attach a separate sheet. Health Professional Memberships Did you serve in the U.S. Armed Forces? Dates of service Month / Year Month / Year If yes, what branch? Have you ever been convicted of a crime other than a minor traffic violation (including DUI or OUI), including during military service? If yes, please explain: (Beaumont Hospitals conducts criminal record checks. Failure to divulge complete information will disqualify you from admission into a Beaumont Allied Health program. However, conviction will not necessarily disqualify an applicant from admission into a Beaumont Allied Health program) Are you charged with or have any pending unresolved criminal charges? (Are you charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication or dropping of the charge? ) If yes, explain fully: Have you ever been suspended or discharged from employment? If yes, please explain: For licensed professionals, have you been or are you currently being investigated by Federal or State governments related to your participation in Medicare, Medicaid or other Federal health programs? If yes, please describe the results of the investigation: Have you ever been subjected to an sanction as a result of a violation of an academic honor code, or suspended or dismissed by an educational program that you attended in order to meet any certification requirement? If yes, please explain: For licensed professionals, have you ever had your license suspended or revoked in any state? If yes, please explain: Can you perform all of the job functions of the position(s) for which you are applying, with or without a reasonable accommodation? (See the Technical Performance Standards for the program to which you are applying for admission) Beaumont Hospital is an equal opportunity employer and complies with all laws prohibiting discrimination on the basis of race, color, age, sex, national origin, religion, citizenship, handicap, height, weight, marital status, and sexual orientation. Under the Michigan Persons with Disabilities Civil Rights Act, Beaumont Hospital and it s training programs have a legal obligation to accommodate a student s disability unless doing so would impose an undue hardship on the hospital (program). A person with a disability may allege a violation against the hospital education program regarding a failure to accommodate his or her disability under the law only if the person with the disability notifies the program director in writing of the need for accommodation upon acceptance into a program or within the 90-day probation period of a program at which time the person with disability knew or reasonably should have known that an accommodation was needed. This does not affect the rights of the individual under the Americans with Disabilities Act of I hereby authorize an investigation of my past employment, activities and statements contained in this application and release from all liability and responsibility all persons, companies or corporations supplying such information. I understand that such information may include a record of disciplinary action assessed by previous employers, and hereby release such parties from any obligation to supply me with written notification of such disclosure. I certify that the above information about myself is correct and understand that misrepresentation of the facts may be sufficient cause for termination. I understand that any admission offer is conditional upon successful completion of a physical examination which includes a drug screen, completion of an education eligibility verification, and upon receipt of satisfactory references. I further declare that I am not using any illegal drugs and do not engage in improper self-medication. I understand that Beaumont Hospital will conduct a criminal background check. Signature Date

4 APPLICATION GUIDELINES 1. Please visit to review the guidelines for submitting an application outlined under the program(s) to which you are applying. 2. Sign below that you have read the Technical Standards/Essential Functions, as stated on the website, for the program you are applying to, you understand them, and whether you can perform them or you need to speak with the program director to discuss possible accommodations. (Check one.) L I have read the Technical Standards/Essential Functions for the program of my choosing, I understand them, and to the best of my knowledge, I can meet the Technical Standards/Essential Functions. L I would like to discuss the areas that the program director, for the program of my choosing, might consider modifying, so that I am able to meet the Technical Standards/Essential Functions. SIGNATURE DATE RETURN TO: Program Director School of (Insert the program you are applying to) Beaumont Hospitals 3601 W. Thirteen Mile Road Royal Oak, Michigan OS7

5 BEAUMONT SCHOOLS OF ALLIED HEALTH STUDENT DISCLOSURE AND RELEASE In connection with my application for admission into the Beaumont Schools of Allied Health, I understand that consumer reports and background checks which may contain public record information may be requested by Beaumont Hospitals or its agents. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, job performance, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers compensation claims, criminal records, school records, etc., from federal, state, other agencies and former employers which maintain such records. All those contacted will be held harmless and free of any legal liability. I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY BEAUMONT HOSPITALS OR ITS AGENTS TO FURNISH THE ABOVE MENTIONED INFORMATION. I have the right to make a request to Beaumont Hospitals or its agents, upon proper identification, to request the nature and substance of all information in its files on me at the time of the request. I hereby authorize procurement of consumer report(s). If admitted into the Beaumont Schools of Allied Health, this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports during the term set forth in the INTERN/WORK OBSERVER/STUDENT AGREEMENT. Print Name Social Security # Applicant s Signature Date 1203A JAN 09 OS7

6 SCHOOLS OF ALLIED HEALTH RECOMMENDATION FORM Program applying to: L School of Radiologic Technology L School of Radiation Therapy L School of Nuclear Medicine Technology L School of Medical Technology L School of Histotechnologist L School of Histologic Technician L School of Polysomnographic Technology L School of Clinical Oncology Massage L Post Graduate CT Program L Post Graduate MRI Program Return to the applicant at: Name of applicant: Applicant: Please follow the letter of recommendation guidelines, which appear from brochure or website and complete the above section before submitting this form to your reference. Reference: The applicant named above has applied to Schools of Allied Health at Beaumont Hospital, Royal Oak, Michigan. maintain confidentiality, please seal the return envelope, sign over the seal and return to the applicant. We are interested in obtaining information that will aid us in selecting capable students. In view of these highly technical and professional careers, it is imperative that we know something more than a transcript reveals. Thus, the Admissions Committee will rely on your honest evaluation of this candidate, and truly appreciate your efforts in this regard. The applicant has selected you as someone who can give us such an appraisal. Your recommendation will remain confidential. I. Acquaintance with Applicant 1. Length of time you have known the applicant: months/years. 2. I have known the applicant as a/an: L student L advisee L teaching assistant L employee L other: 3. My interaction with the applicant was as a/an: L instructor in one class L instructor in several classes L curriculum or major advisor L teaching/research supervisor L employer/supervisor L other: II. Comments (use an extra sheet if needed) Please add any descriptive comments that will aid in providing a complete picture of the applicant s abilities and potential as a student and health care professional OS7

7 Name of applicant: III. Personal and Professional Appraisal: (Please check the category that best indicates your evaluation of the applicant in terms of listed characteristics. Personal Communication Skills: Motivation: Ability: Quality of Work: Maturity: Above Below **No Basis for Characteristics Evaluated Excellent Average Average Average Evaluation a. Appearance (dress, grooming, etc.) b. Reliability c. Integrity a. Oral b. Written c. Listening a. Attitude b. Initiative c. Punctuality/Attendance d. Leadership a. Academic Potential b. Work with People c. Adapt to New Situations d. Analyze Problems and Solve them Effectively e. Interaction with Patients* f. Work Independently a. Organization b. Accuracy c. Technical Competency d. Professional Competency* a. Judgment b. Emotional Stability c. Sense of Responsibility d. Sense of Reasoning *Only those who have had an opportunity to observe the applicant in a health setting should complete this category. **This indicates you have not had the opportunity to observe the applicant in a situation demonstrating this characteristic. IV. Recommendation for Acceptance L Strongly recommend L Recommend Please Type or Print YOUR NAME L Recommend with reservations as noted in the comment section L Do not recommend TITLE ORGANIZATION / BUSINESS / INSTITUTION CONTACT PHONE NUMBER. ADDRESS (CITY, STATE, ZIP CODE) SIGNATURE DATE Please note: It is not possible to thank each individual personally for completing a recommendation form. We want you to know, however, that we are aware of the time required and both we and the applicant are most appreciative of your response OS7

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