Supplemental Application for the Mammography Program

Program Information

Are you currently enrolled in HCC’s Radiography program?: *

Yes

Personal Information

First Name: *

Middle Initial:

Last Name: *

Former Name:

Student ID Number:

Address: *

City: *

State: *

Zip: *

Home Phone: *

Daytime Phone:

Cell Phone: *

Email Address: *

Emergency Contact Information

Name: *

Relationship: *

Phone: *

Education & Training

Please list formal post-secondary schooling, most recent first. Include special training or skills (vocational, military, business)

School 1

School:

City, State:

Dates (From/To):

Course/Major:

Degree/Certification:

GPA:

School 2

School:

City, State:

Dates (From/To):

Course/Major:

Degree/Certification:

GPA:

School 3

School:

City, State:

Dates (From/To):

Course/Major:

Degree/Certification:

GPA:

Expiration Date of State License (if applicable) :

(Students may be required to obtain a license to meet state practice guidelines and clinical education facility requirements.)

State of License:

Date of ARRT Examination (Completed) :

ARRT Number:

Upload Resume/CV:

Additional Information

Have you ever been convicted of a felony or misdemeanor?** : *

Yes

Have you ever had an ethics or honors violation?**: *

Yes

Have you ever been convicted or dismissed for alcohol or drug use?**: *

Yes

**If you answered Yes to any of the above statements, you will be required to submit an Ethics Pre-Application Review with the ARRT. Go to https://www.arrt.org/ethics/preapp.htm for more information. You must be cleared via the ARRT to be eligible for acceptance into the program.

Authorization: *

I authorize the Hagerstown Community College Medical Imaging Program to verify information related to my application. I understand that being accepted into the Hagerstown Community College Mammo program depends on the truthfulness of my application. I understand that clinical placements require meeting additional standards. Information is provided to those who are accepted to the program.

Office Use Only

Received By:

Received On:

Coded in Datatel By:

Coded in Datatel On:

Curriculum Change Processed By:

Curriculum Change Processed On:

Received by Program Coordinator:

Received by Program Coordinator On:

Notes:

Supplemental Application for the Mammography Program

Additional Information: