ADMISSION APPLICATION

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1 ADMISSION APPLICATION 2016 Applicant Name: Last First Middle To Which Program Are You Applying? Paramedic Program Radiography Program Criminal History Notice The American Registry of Radiologic Technologist may deny eligibility to write the certification exam to individuals who have been convicted of a felony or a misdemeanor. Non-Discrimination Statement St Vincent College of Health Professions Radiography Program provides equal opportunity to all applicants. The Program is selective in its admissions practices and evaluates applicants based on merit without discrimination on the basis of age, race, religion, creed, color, national origin, marital status, gender, disability, veteran status, sexual orientation, or any other legally protected status. * Applications will be accepted only between November 1 and January 31 *

2 PERSONAL HISTORY Name: Last First Middle Other name under which transcripts may be listed: Mailing Address: Street City State Zip Telephone: address: Person to notify in case of emergency Name Relationship Street City State Zip Phone Will you be 18 years or older on or before August 1 of the year you seek enrollment? Select your response from the drop down list. Have you applied to this program previously? Select your response from the drop down list. If yes, most recent year applied? Have you ever been convicted of any felony or misdemeanor other than minor traffic violations? Select your response from the drop down list. *If you answered YES to the previous question, attach a description and explanation of your prior conviction history, including date of conviction, court and details of each violation. Disclosure of a criminal record does not automatically disqualify you from admission consideration. How did you first hear about our Radiography Program (check the appropriate box)? Website search Friend or family member is a St Vincent Health hospital associate Friend or family member is enrolled / graduated from the program During a visit to a St. Vincent Health hospital Other

3 ACADEMIC DEGREE HISTORY Official transcripts must be sent from each institution attended; List the most recent colleges first (use additional sheets if needed) Do you currently have any academic degree (Associate, bachelors, masters, etc.) in any discipline? If yes Degree Institution: Date earned: If not, will you have earned any academic degree (Associate, bachelors, masters, etc.) in any discipline by August 1 of 2016? If yes Degree Institution: Date to be earned: Yes No Yes No COLLEGES ATTENDED * If you are currently enrolled in classes, please include a current class schedule * College / School: City & State Dates of Attendance: Major College / School: City & State Dates of Attendance: Major College / School: City & State Dates of Attendance: Major College / School: City & State Dates of Attendance: Major

4 ACADEMIC REQUIREMENTS EFFECTIVE: 2016 Below is a summary of the academic requirements for the program. To be accepted in the program, the applicant must meet the following requirements: All Applicants To be accepted in the program, the applicant must meet the following academic requirements: 1. Minimum 2.50 college GPA (4.00 scale) on all academic work, and 2. Meet one of the two category requirements below: A. Applicants who will have earned any academic degree from a regionally-accredited institution prior to August 1 1. Completion of the following general education areas (see the Approved Course List for courses with standing approval): a. Mathematics / Logical reasoning minimum 3 credit hours b. Communication minimum 3 credit hrs 2. Completion of at least 6 or more credit hours from any of the following general education areas (see the Approved Course List for courses with standing approval): a. Information Systems b. Social / Behavioral Sciences c. Natural / Physical Sciences 3. At least 3 additional credit hours must come from either #1 or #2 above. 4. All of the above courses must be completed with a letter grade of C or better. 5. Any of the above requirements not met by August 1 will have to be approved by program faculty prior to enrollment with the understanding that all requirements will have to be met prior to program graduation. B. Applicants who will not have earned an academic degree from a regionally-accredited institution prior to August 1 1. Completion of the following Ivy Tech Community College courses or equivalent courses from other regionally accredited institutions: * a. APHY 101 b. APHY 102 c. ENGL 111 d. COMM 101 or COMM 102 e. HLHS 101 f. IVYT 1xx (success elective) g. MATH 13x (math elective) h. PSYC 101 or SOCI Completion of at least 12 hours of the above coursework through any regionally-accredited college by January 1, and 3. Completion of at least 9 hours of any 100-level or higher coursework through any Ivy Tech Community College campus by June 1, and 4. Completion of at least 15 hours of any 100-level or higher coursework through any Ivy Tech Community College campus by August 1, and 5. All of the above courses must be completed with a letter grade of C or better. 6. Any of the above requirements not met by August 1 will have to be approved by program faculty prior to enrollment with the understanding that all requirements will have to be met prior to program graduation. * Coursework from other institutions must appear on an official Ivy Tech transcript *

5 Approved In Progress Denied Office Use Only For Candidates who have or will have earned an academic degree by August 1, please complete this page 1. Mathematics (Algebra or higher) (minimum 3 credit hours) Course Title Course # Credits Institution Semester / year Letter Grade 2. Communication (minimum 3 credit hours) At least 6 hours must come from any of the following areas (combined, not each) 3. Information Systems Course Title Course # Credits Institution Semester / year Letter Grade 4. Social / Behavioral Sciences Course Title Course # Credits Institution Semester / year Letter Grade 5. Natural / Physical Sciences Course Title Course # Credits Institution Semester / year Letter Grade Office Use Only Applicant has met all general education requirements for admission Applicant has not met all general education requirements but has met requirements for application Applicant has not met requirements for application

6 Approved In Progress Denied Office Use Only For Candidates who will NOT have earned an academic degree by August 1, please complete this page Ivy Tech Course (or equivalent course) Semester/ Year Institution Letter Grade APHY 101 ( ) APHY 102 ( ) ENGL 101 ( ) COMM 101 or COMM 102 ( ) HLHS 101 ( ) IVYT 1xx ( ) MATH 13x ( ) PSYC 101 or SOCI 111 ( ) Office Use Only Applicant has met all general education requirements for admission Applicant has not met all general education requirements but has met requirements for application Applicant has not met requirements for application

7 EMPLOYMENT HISTORY * Please list the most recent first * Name of Company Address (Street, Cit, State & Zip) Starting Date: Type of Business Position Held Termination Date: Telephone Supervisor Briefly describe your job responsibilities Reason for Termination Name of Company Address (Street, Cit, State & Zip) Starting Date: Type of Business Position Held Termination Date: Telephone Supervisor Briefly describe your job responsibilities Reason for Termination Name of Company Address (Street, Cit, State & Zip) Starting Date: Type of Business Position Held Termination Date: Telephone Supervisor Briefly describe your job responsibilities Reason for Termination

8 CLINICAL SITE PREFERENCE If selected into the program, where would you prefer to be based for your primary clinical rotations (please circle your preference; only one clinical site may be chosen)? ATTESTATION OF HIGH SCHOOL GRADUATION/GED By my signature below, I state that I am a high school graduate or have completed by General Education Development (GED) test or graduated from the equivalent of a high school from another country. STATEMENT OF TRUTH I certify that the information contained in this application is correct to the best of my knowledge and understand that any misstatement or omission of information is grounds for immediate removal from consideration of admission or dismissal from the program if already admitted. I authorize the employment references listed herein to release to you any and all pertinent information concerning my previous employment. I authorize the academic references listed herein to release to you any and all pertinent information concerning my previous enrollment in the institution. I further agree to release all parties from all liability from damage that may result from furnishing said information to you. I acknowledge that I have been made aware The American Registry of Radiologic Technologist may deny eligibility to take the certification exam for individuals who have been convicted of a felony or a misdemeanor. I further acknowledge I have reviewed information regarding the Essential Functions and Skills individuals need to possess to be successful in the Radiography Program and as radiographers online at Signed Date Did you remember to: Submit the completed and signed application by January 31, 2016? Submit the non-refundable $20 application fee by January 31, 2016? (Cash will not be accepted; personal checks are to be made payable to: SVCHP Radiography Program) Submit the typed essay by January 31, 2016? If currently enrolled in college, submit a current class schedule by January 31, 2016? Submit official transcripts from all colleges, vocational, technical or other academic institutions attended by February 10, 2016? Mark your calendar to attend one mandatory Pre Admission Conference (see website for dates and locations)? Send all application materials to: Mark Adkins Radiography Program Director St. Vincent Indianapolis Hospital 2001 W. 86 th Street Indianapolis, IN * All application materials must be mailed or hand-delivered to the address above; application materials will not be accepted at any other location. ** Candidates are encouraged to submit their application materials as soon as possible

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