Limited Permit X-ray Technician Bone Densitometry School ID#6020 CLASS NOTIFICATION

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1 Limited Permit X-ray Technician CLASS NOTIFICATION School information Date: November 6-8, 2015 Time: Friday 7:45 am 7:30 pm Saturday and Sunday 7:30 am 5 pm - Each student s schedule varies Location: 1814 Franklin Street, Suite 620 Oakland, CA Meals: A light breakfast and lunch is provided each day and dinner is provided on Friday. Capacity: We accept the first 8 applications. State requirements that you will receive 1. Eighteen (18) hours of formal classroom education including: 3 hours on radiation physics, biology, and protection 3 hours on bone biology, bone disease and therapy, and densitometry parameters 4 hours on X-ray bone densitometry equipment 3 hours of computers and image formation 4 hours on anatomy and patient positioning 1 hour on ethics and patient handling 2. Four (4) hours of laboratory training where you will use phantoms and evaluate images. 3. Four (4) hours of supervised clinical education where you will do radiographic procedures: 5 scans of the posterior/anterior spine 5 scans of the hip 10 scans of a variety of extremities Fees* Non-Refundable registration fee Tuition State license application fee Total tuition and fees $ $1, $88.00 $1, *All tuition and applicable fees are due at the time of registration. To apply, complete and return Registration Form (signature required in three places) Performance Fact Sheet Cancellation and Refund Policy Admission Questionnaire and attachments as required Copy of California (state) Identification Card If you have any questions about the school, please (510) x1022 Class Notification Only Application begins on the next page. Page 1

2 REGISTRATION FORM Page 1 of 3 Please complete and mail, fax, or back to: FORE 1814 Franklin Street, Suite 620 Oakland, CA Fax: (510) Student Information Last Name First Name Address City State Zip _ _ Daytime phone Date of birth (required) Fax number _ Current occupation Do you have access to a DXA Machine? No Yes Manufacturer Fees* Non-Refundable registration fee $ Tuition $1, State license application fee $88.00 Total tuition and fees $1, *All tuition and applicable fees are due at the time of registration. Payment** Check enclosed for $ Credit Card Expiration Date ** In order to pay for your tuition by a check, we are required a credit card number on file. Your credit card will not be charged without notifying you. VISA MasterCard AMEX Discover Name as it appears on Card Card Number Card Holder s Expiration Date Page 2

3 REGISTRATION FORM Page 2 of 3 This registration will not become operative until you attend the first day of. Location Name FORE 1814 Franklin Street, 9 th Floor Conference Room Oakland, CA (510) x1022 Limited Permit X-ray Technician: Date November 6-8, 2015 Fee $1, FORE is registered with the State of California. Registration means we have met certain minimum standards imposed by the state for registered schools on the basis of our written application to the state. Registration does not mean we have met all of the more extensive standards required by the state for schools that are approved to operate or licensed or that the state has verified the information we submitted with our registration form. CANCELLATION AND REFUND POLICY FORE shall refund for all students, without penalty or obligation, the total tuition and fees less the non-refundable registration fee of $200, if notice of cancellation is made 10 business days prior to the first day of. Any cancellation made within 10 days of the first day of forfeits 50% of the tuition charges plus the non-refundable registration fee. Should the student withdraw and complete 60 percent or less of the course the student will receive a pro rata refund. The amount owed by the student for the purpose of calculating a refund is derived by multiplying the total hours attended by the hourly charge of $75.83 for, plus the non-refundable registration fee of $200. The refund shall be any amount of excess as shown on the following page. Any notification of the withdrawal or cancellation and any request for a refund is a required to be in writing. FORE shall pay for credit refunds due on a reasonable or timely basis, not to exceed 30 days following the date upon which the student s withdrawal has been determined. Page 3

4 REGISTRATION FORM Page 3 of 3 Examples of the application of the cancellation and refund policy Cancellation prior to 10 days of the first day of Cancellation 10 days or less than the first day of You forfeit 50% of tuition Cancellation after 8 hours of You forfeit 50% of tuition plus the hourly rate Cancellation after 10 hours of You forfeit 50% of tuition plus the hourly rate Non-Refundable Registration Fee $ $ $ $ Tuition Charge $1, $1, $1, $1, Less Instructional Charge of $75.83 / hour $0.00 $0.00 $ $ State Application Fee $88.00 $88.00 $88.00 $88.00 Refund Due* $1, $ $ $ This is a legally binding agreement when signed by you and accepted by FORE. Any cancellation made within 10 days of the first day of forfeits 50% of the tuition charges plus the non-refundable registration fee. Print Student Name Date FORE Program Coordinator Date Page 4

5 SCHOOL PERFORMANCE FACT SHEET THE FORE SCHOOL The FORE Limited Permit X-Ray Technician School is not an entry-level course. The school is three days of intensive training. FORE is not able to tell you how many students graduate, how many find jobs, or how much money a student can earn after finishing this school. REQUIREMENTS TO PASS A Certificate of Completion is required for students to apply to take the State of California Bone Densitometry Equipment Operator Examination to receive a Limited Permit in X-Ray. To receive a certificate of completion from FORE, students must pass a 60 question written exam with 80% correct answers AND be deemed competent to perform bone density scans as evaluated by a clinical instructor. If a student fails the FORE written exam, they may take a re-test for a fee of $ If a student is not deemed competent to perform bone density scans, they may return for remedial work for an additional fee of $ NOTICE CONCERNING TRANSFERABILITY OF UNITS AT OUR SCHOOL The certificate of completion you earn at FORE s Limited Permit X-Ray Technician School will not be transferable to any college or university. In addition, when you earn a certificate of completion from the school it will not serve as a basis for obtaining a degree at a college or university. I understand the school performance fact sheet and agree to all of the requirements. Print Student Name Date FORE Program Coordinator Date Page 5

6 ADMISSION QUESTIONNAIRE This Limited Permit X-Ray Technician School is not entry level, but an intensive three day training program to prepare you to sit for the State of California Limited Permit Equipment Operator Examination. To ensure your success, we will review this questionnaire prior to admitting you to the school. If we believe you may not be a suitable candidate to successfully pass the coursework, we will contact you. 1. What is your name? 2. What is your current job title? 3. Do you or have you had any experience in the health field? If yes, please explain. 4. Do you have any radiology or imaging experience? If yes, please explain. 5. What is the highest level of education you have completed?* High School/GED 2-year Associate Degree 4-year Bachelor s Degree Masters PhD or MD * Please attach proof of completion 6. Please attach the following: Resume Anatomy and/or physiology course (unofficial transcript is okay) Other related course work (please specify): Page 6

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