Widener-Crozer Allied Health Program

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1 Application for Admission prog code/major start term FOR OFFICIAL USE ONLY There is no application fee. Please print (use dark ink). Please mail to the Main Campus. 1. Name Last First Middle Maiden 2. Address City County State Zip 3. Phone number Work Home Cell 4. Social Security Number 5. Are you a citizen of the United States? Yes No If not, state your country of citizenship If you are not a citizen, are you a permanent resident of the United States? Yes No Permanent resident number If no, please contact the Day Admissions Office. 6. address 7. Select one start date for clinical classes to be taken after completion of pre-requisite and degree courses: Radiography Program OR Diagnostic Medical Sonography Program January 20 January 20 July 20 September Have you previously attended Widener? Yes No If yes, attended Continuing Studies from to or attended day school from to 9. Please indicate if you will be applying for financial aid. Yes No 10. This information is optional and will be used for statistical purposes only: Do you consider yourself to be Hispanic/Latino? Yes No In addition, select one or more of the following racial categories to describe yourself: American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White Male Female Place of Birth Date of Birth Widener University, One University Place, Chester, PA, Phone:

2 11. I wish acceptance into the following major/program: Radiologic Technology Diagnostic Medical Sonography 12. Employer Occupation Address Will your employer subsidize your education expense? Yes No If yes, explain how (full, partial refund, grade based, etc.) 13. If you are/have been in the military, please check one of the following: Status: on active duty in reserves veteran Service branch: 14. List below the high schools and all other colleges you have attended. Attach an additional sheet if necessary. High School or College Name Location From To Year Year Graduated (yes or no) If yes, list major Please send: 1. College transcript. If you attended any other college(s) prior to Widener University, you must request that a copy of your college transcript(s) be mailed directly from that institution(s) to the Continuing Studies office. We must receive a transcript from each college attended before you can be admitted as a matriculated student. Students who do not disclose prior college records at the time of application are subject to dismissal when prior attendance is discovered. 2. Proof of high school completion. All students seeking admission to degree status must be either high school graduates or have earned a G.E.D. Proof of high school completion must be submitted to Continuing Studies. 3. Check here if you have advanced placement credits. 4. If you attended high school or college under a different name, please ask the institution(s) to indicate your current name on the transcript. 15. Have you ever contacted of Widener or Crozer before? Yes No If no, how did you hear about Continuing Studies or Crozer? personal referral recruitment event location Web site advertisement, please specify (radio, newspaper, GroW, etc.) other (please specify) If this application is accepted, I agree to assume the obligations set forth in the catalog effective with my acceptance. To the best of my knowledge, the information on this application is accurate. Signature Date It is the policy of Widener University not to discriminate on the basis of sex, age, race, national origin or ethnicity, religion, disability, sexual orientation, or marital status in its educational programs, admissions policies, employment practices, financial aid, or other school-administered programs or activities. This policy is enforced under various federal and state laws, including Title VII of the Civil Rights Act of 1964 as amended by the Civil Rights Act of 1991, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination in Employment Act, and the Americans with Disabilities Act. Further, in compliance with state and federal laws, Widener University will provide the following information upon request to the Vice President for University Advancement, Widener University, One University Place, Chester, PA 19013, : (a) copies of documents pertinent to the university's accreditations, approvals, or licensing by external agencies or governmental bodies; (b) reports on crime statistics and information on safety policies and procedures; and (c) information regarding gender equity relative to intercollegiate athletic programs. Comments or requests for information regarding services and resources for disabled students should be directed to: Director of ENABLE, Widener University, One University Place, Chester, PA 19013, , or Dean of Students, Delaware Campus of Widener University, P.O. Box 7474, Wilmington, DE 19803, Published by the Office of University Relations, 03/10.

3 RECOMMENDATION On behalf of. The above named person is applying for admission to the Widener-Crozer Allied Health Program. The school would like your frank opinion of this candidate, and would appreciate your thoughtful attention to this recommendation. In addition to the requisite skills, there are many personal characteristics involved in the selection of students who will serve in the healthcare field. Of these, we are particularly interested in: MOTIVATION, JUDGMENT, INITIATIVE, COOPERATION, and the ABILITY TO COMMUNICATE, both in WRITING and VERBALLY. Please attach a letter detailing some examples of situations where your candidate has demonstrated these characteristics. How well do you know this candidate? VERY WELL REASONABLY WELL SLIGHTLY In what capacity do you know the applicant? Has there been any reason to question the candidate s integrity? YES NO (If yes, please explain). The applicant is: HIGHLY RECOMMENDED RECOMMENDED NOT RECOMMENDED RETURN TO: Nancy Maffia Widener University One University Place Chester, PA Printed Name: Signature: Position: Phone: Address:

4 RECOMMENDATION On behalf of. The above named person is applying for admission to the Widener-Crozer Allied Health Program. The school would like your frank opinion of this candidate, and would appreciate your thoughtful attention to this recommendation. In addition to the requisite skills, there are many personal characteristics involved in the selection of students who will serve in the healthcare field. Of these, we are particularly interested in: MOTIVATION, JUDGMENT, INITIATIVE, COOPERATION, and the ABILITY TO COMMUNICATE, both in WRITING and VERBALLY. Please attach a letter detailing some examples of situations where your candidate has demonstrated these characteristics. How well do you know this candidate? VERY WELL REASONABLY WELL SLIGHTLY In what capacity do you know the applicant? Has there been any reason to question the candidate s integrity? YES NO (If yes, please explain). The applicant is: HIGHLY RECOMMENDED RECOMMENDED NOT RECOMMENDED RETURN TO: Nancy Maffia Widener University One University Place Chester, PA Printed Name: Signature: Position: Phone: Address:

5 Technical Standards Sign-off I realize that the following technical standards are a description of the physical demands and sensory requirements needed for professionals who will work in the field of radiology. Because part of the training for the Widener-Crozer Allied Health Program requires me to participate in clinical education in a manner that will enable me to assume the duties of an entry level technologist upon graduation, I must be capable of doing the following to meet the technical standards of the program. The Technical Standards are as follows: Extremely heavy physical effort: lift/carry over 50 lbs Prolonged, extensive or considerable standing/walking Maintains upright position, over a prolonged period of time, without external support Very good balance Excellent control of voluntary muscle movements Lifts, positions, pushes and/or transfers patient. Lifts equipment/supplies Pushes/pulls, moves/lifts heavy equipment/supplies Transports patients in wheelchairs and litters Considerable reaching, stooping, bending, kneeling, crouching Hearing sensitivity bilaterally within normal limits (0-24.db HL); aided/non-aided and/or speech discrimination within functional limits for telephone and personal communication Visual acuity of 20/60 in at least one eye with or without correction Color perception Ability to verbally communicate the English language Good written communication skills. I have reviewed the above standards and agree that I am capable of meeting these requirements. My signature confirms this to be a true statement. Signature: Print Name: Date: If my ability to perform these standards changes prior to the start of the program, I MUST notify the program to be re-evaluated. Failure to meet the standards prior to immediate start of the program will result in my release and nullification of all agreements. I understand that this requirement is mandatory. Signature: Print Name: Date:

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