Please note that all dates, times and fees listed are subject to change without notice.

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1 May 21, 2012 Dear Prospective Student: Thank you for considering Simi Valley Adult School and Career Institute as you pursue a career as an X-ray Technician. This is a limited permit program that prepares students to take the California State Board Radiography Examination in categories of chest, torso skeletal, and extremities. Graduates work primarily in doctor s offices, clinics, and medical groups, and may continue at another school to advance to a full license. Please read this letter carefully, as it will explain the first part of the application process for the fall 2012 program. Due to the large number of applications submitted for the spring 2012 class, there were many eligible applicants who were alternates. Those on that alternate list will receive priority as far as acceptance into the spring class, but does not guarantee acceptance the following semester. There is a $ non-refundable application fee that must be submitted with the application. The application fee must be paid in cash, money order or cashier s check. No personal checks, debit or credit cards will be accepted for the application fee. Applications must be received in the Counseling Office no later than 3:30 p.m. on Friday, July 20, Applications arriving after this time, or submitted with or without the application fee, will be returned to the applicant. This is a 25-hour per week daytime program that will begin August 27, 2012, with graduation scheduled for August 2013; however, because of clinical requirements, students may need to continue beyond this date in order to fulfill state-mandated examination totals. The anticipated total cost of the program is approximately $4, Please note that all dates, times and fees listed are subject to change without notice. By the first class meeting, all students must be at least 18 years of age be graduates of an accredited U.S. high school or have passed the English-language version of the GED. Associate s (or higher level) degrees from a U.S. institution are also acceptable. Foreign diplomas or degrees are not accepted. All students must have either the American Heart Association CPR for Healthcare Provider card or the American Red Cross CPR for the Professional Rescuer card. This is not a requirement for admission to the program, but it is a requirement prior to beginning the clinical portion of the program. A CPR for the Healthcare Provider class will be offered, for a fee, during your classroom instructional time or you may take a CPR for the Healthcare provider class independently. Additional information will be provided to you by your instructor at the start of your program. Page 1 of 7

2 A mandatory background check is required for consideration as a student for the X-Ray Technician program. The majority of our clinical sites are now requiring a criminal background check of every student prior to the student reporting to the clinical site. Selection into the X-ray Technician program is based upon a point system. Candidates earn points from three different areas: the entrance test, the oral interview and the essay. A minimum of 75% of the overall total points must be earned to be eligible for the program. Application Instructions The application is the first step in the application process for the X-ray Technician program. Your ability to follow instructions will be evaluated in the way in which you complete the application. If you wish to apply for more than one program, you must submit a separate application and fee for each program. Applications downloaded from the internet cannot be completed on line. You must print out the four-page application and complete it following the instructions below. It is also recommended you print out this cover letter to keep for future reference. If you choose to mail your application, mail it to: Simi Valley Career Institute 1880 Blackstock Avenue Simi Valley, CA Attn: Kris Owen Applications should be typed or completed in black or blue ink. Do not use pencil. If a question or an area does not apply to you write N/A in the appropriate space. Do not leave a blank. Page 1: This page provides us with general information about you. Under Personal, please give your full first name. Do not put a nickname unless it is the name used on transcripts and other documents. Be sure to list all last names you have used. Documents received with names other than the ones listed on your application may not find their way to your file because we have no record of a candidate using that name. Give the address and phone number where you can be most easily reached. Please do not put pager numbers. The school does not have a residency requirement so you do not have to have a local address. Page 2: This is a record of your employment history. Please read the instructions at the top of the page and give the information as it is requested. Page 3: This is your health history. Please complete this as accurately and completely as possible. This does not take the place of the physical examination required if you are accepted. You may be asked questions about your health history at your interview. This is NOT a means of disqualifying applicants. Depending upon your condition or disability, you may be asked to bring a note from your doctor clearing you to perform the necessary duties during class or clinical. If you have a disability and choose not to declare it, the adult school is under no obligation to provide accommodations. Page 2 of 7

3 Page 4: This provides us with information as to your status regarding completion of the program prerequisites. It is also the signature page indicating you have read and understand the terms of the application. Once we receive your application, you will receive an information packet. This will include the form on which to write your essay and a form for you to use to request a transcript from your high school, GED testing center or college. Also included is information about the interview and point total system. We recommend retaining this letter for the duration of the process as you may wish to refer to some of the information contained herein. If you have any questions regarding any of the information contained in this letter or anything about the process, please call me at ext If you should get my voice mail, please leave a message with your name and number where you can easily be reached and I will return your call as soon as possible. Sincerely, Nicole Pacheco Allied Health Counselor NP/ko Page 3 of 7

4 19 36 SIMI VALLEY ADULT SCHOOL AND CAREER INSTITUTE X-RAY TECHNICIAN PROGRAM APPLICATION 2012/2013 Deadline to Submit no later than 3:30 p.m. on July 20, 2012 Please print clearly using black or blue ink. Complete all areas of the application and provide all information requested. If an area does not apply, write N/A. Points will be deducted for failure to follow the application directions. PERSONAL NAME: Last First Middle Other Names Used ADDRESS: City State Zip ADDRESS (required) : DAYTIME PHONE: EVENING PHONE: EDUCATION (Foreign degrees or diplomas are NOT accepted) Name of School Location of School Course of Study Diploma? Degree/Cert.? High School: College: Voc/Tech School: If you received your GED in lieu of a high school diploma, please provide the following information: GED Date: GED Testing Center: For Office Use Only Receipt #: Date: Received By: Page 4 of 7

5 EMPLOYMENT HISTORY List all employment during the past five years starting with your present employer. Add any prior employment pertaining to the medical field (i.e. Medical Assistant, Nurse Assistant, E.M.T., etc.) REGARDLESS OF HOW LONG AGO THE WORK WAS PERFORMED. May we contact the following employers for additional information? Yes No Page 5 of 7

6 HEALTH QUESTIONNAIRE Within the past ten years have you received medical treatment for any of the following? All Yes answers must be explained in the area below.** Yes No Yes No Yes No Asthma Hepatitis Shortness of Breath Backaches/Injuries Hernia Coughing up Blood Diabetes High Blood Pressure Tuberculosis Epilepsy/Convulsions Impaired Hearing Indigestion Dizziness/Fainting Impaired Vision Heart Disease Kidney Disease Lung Disease Varicose Veins Frequent Nosebleeds Mental Illness Chest Pains Persistent Cough Rheumatic Fever Allergies Rheumatism/Arthritis Skin Rashes/Diseases Cancer or Tumors Injuries Other Serious Illnesses Operations **Explain all YES answers here. Do you declare a disability? No Yes, please explain: I, the undersigned, certify that the above answers are true and correct. Signature: Date: Page 6 of 7

7 PLEASE READ CAREFULLY BEFORE SIGNING I certify that all information that I have given is true and complete. I further understand that any serious discrepancies on the application form may jeopardize my status as a candidate. Any of the persons listed by me in this application are hereby authorized to furnish Simi Valley Career Institute with information regarding my character, abilities, personal conduct and other data necessary to process my application. I am aware that completion of this application will NOT automatically place me into the X-ray Technician program at Simi Valley Career Institute and that subsequent testing and interviewing will be required. I understand that I will be granted an interview ONLY if I have met the basic program requirements. I understand that before I am assigned a clinical site, I must have a current American Heart Association CPR for Healthcare Provider card or American Red Cross CPR for the Professional Rescuer card. I also understand that this is at my own expense and is not included in the approximate total cost of the program. I understand that all expenses incurred in the application and acceptance processes which may include, but not be limited to, application fees, a physical examination, and laboratory tests will be paid by me and will not be refunded regardless of whether or not I am accepted. Signature of Candidate Date Page 7 of 7

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