Required fields are marked with an asterisk *. Research Medical Center School of Radiologic Technology Application for Program AdmissionDateApplicantName *Street Address *City *State *Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *Cell PhoneHome PhoneEmail Address *Emergency ContactName *RelationshipStreet Address *CityStateSelect StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip CodePhoneAre you at least 18 years old? * Yes NoHave you applied to this program in the last 3 years? * Yes NoAre you a citizen of the United States? * Yes NoNon US Citizens:Country of CitizenshipVisa ClassificationArrival Date in U.S.Permanent Residents, Alien Card numberList All Educational Institutions Attended (in chronological order from the most recent) College, University, Technical, High School City State Attendance Dates Credits Earned GPA Degree or Certificate Date Received or Expected Academic Courses Currently in Progress (must be completed prior to the start of the Program) Educational Institute Name of Course Credits Expected Completion Date Employment History (chronological record of part-time or full-time employment) Employer Position Dates of Employment Please describe any experience you have in health care occupations or volunteer positions in a hospital, clinic or extended care facility.How did you hear about the Radiology Program at Research Medical Center? Criminal Procedures and Ethics Requirements for ARRT CertificationAccording to https://www.arrt.org/Certification, every candidate for ARRT certification must "be a person of good moral character and must not have engaged in conduct that is inconsistent with the ARRT Rules of Ethics," and they must "agree to comply with the ARRT Rules and Regulations and the ARRT Standards of Ethics." ARRT investigates all potential violations in order to determine eligibility. Issues addressed by the Rules of Ethics include convictions, criminal procedures, or military court martials, felonies, misdemeanors, and/or criminal procedures resulting in a plea of guilty or nolo contendere (no contest), a verdict of guilty, withheld or deferred adjudication, suspended or stay of sentence, or pretrial diversion. Juvenile convictions processed in juvenile court and minor traffic citations not involving drugs or alcohol do not need to be reported. Additionally, candidates for certification are required to disclose whether they have ever had any license, registration, or certification subjected to discipline by a regulatory authority or certification board (other than ARRT). Applicants may complete a pre-application (https://www.arrt.org/pdfs/Ethics/Ethics-Review-Pre-Application.pdf ) to determine their ethics eligibility prior to enrolling in or during their educational program. I have read the above paragraph and agree to inform the program of any situation which may require an Ethics Review Pre-Application from the ARRT. *The final selection of applicants is contingent upon passing a physical examination administered by Research Medical Center and testing negative for illegal drugs in a urinalysis test.Before your application can be processed, the School of Radiologic Technology must receive: Completed and signed application form before December 1st. Copies of all official transcripts submitted directly from high school and colleges. Two (2) completed and signed reference forms. Verification of a job shadow observation. Two-page essay on how you became interested in radiology, why you want to be a radiographer, and the role of a radiologic technologist in the imaging profession. Application fee of $40.00 (check, money order, or cashier’s check) made payable to Research Medical Center. o Fee will be refunded if the applicant cancels the application within 3 working days of receipt of the fee by the school. It is the applicant’s responsibility to confirm all required information has been received by the program by December 1st. I certify that the information provided on this application is true to the best of my knowledge. I realize falsification of this application is grounds for denial or expulsion from the program. * Mail the Completed Application to: Research Medical Center School of Radiologic Technology 2316 E. Meyer Blvd. Kansas City, Missouri 64132 816.276.3390RMC School of Radiologic Technology Equal Opportunity RecordEqual Opportunity Programs are required by the Federal Government to provide statistical information about applicants to demonstrate that the program meets equal opportunity requirements.Your completion of this form is voluntary and would be greatly appreciated.This information will be kept separate and confidential from the applicant’s file and will not be considered in any way todetermine eligibility/acceptance to the program.Gender Male Female Other Do not wish to answerRace American Indian or Alaskan NativeAll persons having origins in any of the original people of North America and who maintain cultural identification through tribal affiliation or community recognition. Asian or Pacific IslanderAll persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Pacific Islands. This includes for example: China, Japan, Korea, the Philippine Islands and Samoa. Also, persons from Bangladesh, Bhutan, India, Nepal, Pakistan, Sukkim and Sri Lanka. Black (not of Hispanic Origin)All persons having origins in any of the Black racial groups of Africa. HispanicAll persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture, regardless of race. White (not of Hispanic origin)All persons having origins in any of the people of Europe, North Africa and the Middle East. Do not wish to answerAre you a Vietnam Era Veteran? Yes NoA person who served on active duty in Vietnam between 02-28-61 and 05-07-75 for a period of 180 days or who was on active duty between 08-05-64 and 05-07-75 but not in Vietnam, and was discharged or released with other than a dishonorable discharge or for a service connected disability.Are you a Disabled Veteran? Yes NoA person entitled to disability compensation under laws administered by the Veterans Administration for disability rated at 30% or more, or a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.RMC School of Radiologic Technology Equal Opportunity RecordA person considering a career in the radiologic sciences can make a better-informed career decision if it is based on personal experiences or observations. The School requires that all applicants to the Research Medical Center’s Program must perform a job shadow of the Imaging Department at Research Medical Center. Please call (816) 276-3296 to schedule a job shadow.Professional dress is required when observing at the department. Jeans, t-shirts, sweatshirts, and open-toed shoes are not allowed. No pierced jewelry should be worn with the exception of one or two earrings per earlobe. Overall appearance should be professional.Please bring this form with you when you observe in the department.Applicant NameRadiology Department/Address *Technologist NameDate of Observation *Time of Observation *Exams Observed *Comments from applicant and/or technologistResearch Medical Center School of Radiologic Technology Reference Form Following is a list of characteristics that we feel are required for a student to successfully complete the educational completing this form and returning it to the applicant in a sealed envelope to the school. Characteristics Description 4 - Outstanding 3 - Satisfactory 2 - Needs improvement 1 - Unsatisfactory N - Not observed or no basis for judgment Responsibility Dependable and accountable for one’s actions 4 3 2 1 N Leadership Demonstrates the ability to direct the activity of others 4 3 2 1 N Initiative Motivated to pursue actions independently; self-starter 4 3 2 1 N Flexibility Capable of responding or conforming to changes or new situations 4 3 2 1 N Organizational Skills Systematically plans for optimal efficiency 4 3 2 1 N Self-Confidence Assured in one’s ability and skills 4 3 2 1 N Independent Worker Completes tasks with minimal supervision 4 3 2 1 N Communication Verbal Contributes knowledge and opinions in an articulate, understanding and non-threatening manner 4 3 2 1 N Communication Written Expresses self clearly in writing 4 3 2 1 N Response to Stress Maintains composure and ability to listen 4 3 2 1 N Positive Attitude Maintains optimistic approach to people and the task at hand 4 3 2 1 N Manual Dexterity Ability to perform psychomotor skills 4 3 2 1 N Interpersonal Skills Ability to work and get along with others 4 3 2 1 N Judgment Demonstrates a constructive approach to problem solving and decision making 4 3 2 1 N Maturity and Professionalism Demonstrates common sense, tact and appropriate behavior 4 3 2 1 N Knowledge Base Demonstrates common sense, tact and appropriate behavior 4 3 2 1 N Dependability Follows through on assignments; meets deadlines 4 3 2 1 N Punctuality Prompt, arrives at the proper time 4 3 2 1 N Attendance Has a record of good attendance 4 3 2 1 N Multi-tasking Ability to manage numerous tasks effectively and efficiently 4 3 2 1 N Criticism and Conflict Resolution Accepts criticism readily and is able to work through conflicts to a positive end 4 3 2 1 N Rate Your Experience Submit SuccessThe form was successfully sent. 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