POLK STATE COLLEGE APPLICATION FOR ACCEPTANCE COMPUTED TOMOGRAPHY ADVANCED TECHNICAL CERTIFICATE PROGRAM. Name: Last First Middle.

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1 POLK STATE COLLEGE APPLICATION FOR ACCEPTANCE COMPUTED TOMOGRAPHY ADVANCED TECHNICAL CERTIFICATE PROGRAM STUDENT INFORMATION: Name: Last First Middle Former Name(s): Student ID #: Mailing Address: City State Zip County Phone Numbers: Home Cell Work If you have you previously applied to, or been enrolled in, another limited access Health Science program in the past 12 months, please indicate which ones and date completed: Indicate the current professional certification(s) you hold Radiography (ARRT) Radiation Therapy (ARRT) Nuclear Medicine (NMTCB) Associate or Bachelor s degree Associate or Bachelor s degree Associate or Bachelor s degree **Required: Attach a current copy of license or certificate to this application Revised November,

months, please indicate which ones and date completed: Indicate the current professional certification(s) you hold Radiography (ARRT) Radiation Therapy (ARRT) Nuclear Medicine (NMTCB)

2 Name Student ID# Health Care Employment Please provide the following information regarding your employment in the field of your specific certification: Employer: Supervisor: _ Address: Phone: Position: Dates Employed: Specific Job Duties: Employer: Supervisor: _ Address: Phone: Position: Dates Employed: Specific Job Duties: **Required: Submit documentation, on official letterhead, of employment held within 12 months of application submission in the area of certification for one of the three modalities (include specific job duties, dates of employment). Revised November,

Position: Dates Employed: Specific Job Duties: **Required: Submit documentation, on official letterhead, of employment held within 12 months of

3 Name Student ID# LICENSURE INQUIRY/INFORMATION: State and national regulations provide that the denial of a license/credential may occur if an individual is habitually intemperate, addicted to, or is found to be in illegal possession or involved in the sale of distribution of habit forming drugs, and/or is unfit or incompetent by reason of gross negligence, physical or mental condition or other like causes which could result in behavior that interferes in his/her practice as a health professional. Please answer the following questions below. A "yes" answer to any question could result in the denial of a license/credential. **If your answer to any of the questions is "YES", you must meet with the Program Director of the program prior to the submittal of the application to the program. Yes No Have you ever been convicted or have you entered a no contest or guilty plea-regardless of adjudication-offense other than a minor traffic violation? Yes No Have you ever been denied or is there now any proceeding to deny your application for a license to practice a health profession in Florida or any other jurisdiction? Yes No Have you ever had a disciplinary action taken against your license to practice a health profession by the licensing authority in Florida or any other jurisdiction? Yes No Have you ever surrendered a license to practice in a health profession in Florida or any other jurisdiction while any such disciplinary charges were pending against you? **I certify that I have read and understand the standards indicated above regarding licensure/credentialing as a health professional at both the state and national level. Applicant's Signature Date TO BE COMPLETED (IF NECESSARY) BY PROGRAM DIRECTOR I have informed the above-identified applicant regarding the licensing/credential process in relation to previous criminal convictions. Program Director Date Revised November,

like causes which could result in behavior that interferes in his/her practice as a health professional. Please answer the following questions below.

4 Name Student ID# THIS CERTIFICATION IS TO BE COMPLETED BY ALL APPLICANTS I hereby certify that the facts set forth in this application are true and complete to the best of my knowledge. I understand that discovery of any falsification of this information will result in denial of admission or prompt dismissal from the program. I understand that, if admitted to this program, I must submit to a criminal background check and drug screening, document immunizations and other requirements for clinical participation, and be free of offenses that would disqualify me from the program. I understand that all courses are offered online with the exception of the clinical practicum course. Applicant's Printed Name Date Applicant's Signature (to be signed in presence of notary) Sworn to and subscribed before me at This day of _, 20 Notary Public or other officer authorized to take acknowledgement. Personally Known OR Produced Identification Type of Identification Produced Revised November,

I understand that, if admitted to this program, I must submit to a criminal background check and drug screening, document immunizations and other requirements for clinical participation, and be free

5 Name Student ID# APPLICATION CHECKLIST The following are minimum requirements for consideration of the application for admission to the Computed Tomography Advanced Technical Certificate Program. Complete each requirement and initial beside each requirement that has been met. Please submit completed application directly to Kerry Shapiro, academic advisor for Airside Center, for evaluation and required signature. **Please do not mail or fax this application as its receipt will not be guaranteed. Failure to complete all requirements will dismiss the applicant from the selection process for the upcoming class. Note: Acceptance to Polk State College does not guarantee admission into the Computed Tomography Advanced Technical Certificate Program. Minimum Admission Requirements: Admission to Polk State College with all required admission documents received by the Registrar's office. Proof of graduation with an associate in science or associate in applied science from an accredited program in radiography, radiation therapy, or nuclear medicine with a minimum overall 2.5 GPA. Must have graduated within the last year if not currently employed in your discipline. Registered as a member in good standing in one of the following disciplines: Radiography (ARRT), Radiation Therapy (ARRT), or Nuclear Medicine (ARRT/NMTCB). Copy of certification must be provided. Documentation on official letterhead of employment held within 12 months of application submission in the area of certification. Contact academic advisor Kerry Shapiro (kshapiro@polk.edu) to submit completed application. **I have completed all of the above requirements and attest that I am submitting a completed application. Applicant s Signature _ Date Academic Advisor Signature Date Stamp (Kerry Shapiro) **Receipt given to student (Advisor initials) Revised November,

Please submit completed application directly to Kerry Shapiro, academic advisor for Airside Center, for evaluation and required signature.

6 Name Student ID# If accepted, applicant will be contacted by Program Director by February 26, 2016 with date and time of mandatory orientation. During this mandatory orientation, additional program information and requirements will be presented to the student that include: Physical and Immunizations (submission of physical exam and documentation of required immunizations) Background Check (completion of required background check) Drug Screen (completion of drug screen) Current CPR (proof of current BLS healthcare provider CPR) Program textbooks and course registration for program (classes begin summer term) Online course information Clinical assignment information and paperwork Any questions, please contact: Beth Luckett Radiography Program Director Polk State College, Airside Center 3515 Aviation Drive 3515 Aviation Drive Lakeland, FL Lakeland, FL Kerry Shapiro Enrollment Services & Outreach Coordinator Academic Advisor, Airside Center Polk State College is committed to and encourages equal opportunity/equity/access for its programs, services, and activities. Revised November,

documentation of required immunizations) Background Check (completion of required background check) Drug Screen (completion of drug screen) Current CPR (proof of current BLS healthcare provider CPR)

POLK STATE COLLEGE APPLICATION FOR ACCEPTANCE OCCUPATIONAL THERAPY ASSISTANT PROGRAM. Name: Last First Middle. Former Name(s):

POLK STATE COLLEGE APPLICATION FOR ACCEPTANCE OCCUPATIONAL THERAPY ASSISTANT PROGRAM STUDENT INFORMATION: Name: Last First Middle Former Name(s): Student Identification Number: D.O.B Phone Numbers: Home