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Wellspan Job Application document sample
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WELLSPAN HEALTH RADIOGRAPHY PROGRAM
Application for Admission to class beginning September _________ (year)
PERSONAL INFORMATION
Name: __________________________________________________________ ____________________
Last First M.I. Social Security #
Former Name: ___________________________________________________________ _______________
(If any) Last First Middle Initial
Home Address: ____________________________________________________________________
Number and Street
____________________________________________________________
City State Zip Code
Home Cell
Telephone: ( )____________________ Telephone: ( )__________________
E-Mail Address: ____________________________________________________________
Person to be notified in an Emergency:
Name: ____________________________________ ____ Relationship:____________________
Address: _____________________________ _____________________________________
Telephone Number: ( )_______________________
Are you a citizen of the United States or a national of the United States or an Alien lawfully for permanent
residence or an Alien authorized to work in the U.S? □ Yes □ No
If No, type of entry document and serial number: ____________________________________
Are you fluent in a second language? □ Yes □ No If Yes, indicate second language: _________________
Have you been convicted or under indictment for a misdemeanor or felony? □ Yes □ No
If yes, provide a letter of explanation.
Note: A conviction will not necessarily prevent admission to the WellSpan Health Radiography Program.
Nature of offense, aggravating and mitigating circumstances, and future eligibility for ARRT certification will be
considered. Candidates must seek pre-approval through the ARRT.
Revised 9/04/08 1
EDUCATION
List all High School and Post-High School experiences in chronological order. Any additional school please
attach with a separate sheet of paper. Official transcripts from high school and all institutions attended
must be sent to the school.
Name of Schools City/State Course of Diploma/Degree Dates
Study Attended
High School
College, Technical, Other School From To
Graduated?
□ Yes □ No
College, Technical, Other School From To
Graduated?
□ Yes □ No
College, Technical, Other School From To
Graduated?
□ Yes □ No
If you hold a High School Equivalency or GED please list: State ________________________________
Date Received _________________________
Certificate Number ____________________
If you are attending or have attended a Radiography Program give the following:
Name of School: ________________________________________________________________________
Address: ________________________________________________________________________
Date of Entrance: _________________________ Date Withdrew: ________________________
Reason for Leaving:
____________________________________________________________________________________________
____________________________________________________________________________________________
______________________________________________________________________________________
Revised 9/04/08 2
REFERENCES
List three references. Select from the following: Professional, Academic, or Employer.
Please have each individual listed submit a written reference to the school.
1. Name __________________________________________ Title ________________________
Address ________________________________________________________________________
Street City/State Zip Code
2. Name __________________________________________ Title ________________________
Address ________________________________________________________________________
Street City/State Zip Code
3. Name __________________________________________ Title ________________________
Address ________________________________________________________________________
Street City/State Zip Code
EMPLOYMENT HISTORY
Please begin with your current or most recent employment. List all employers within the previous 5 years.
Use an additional sheet of paper if necessary.
______________________________________________________ ______________________________
Employer Employed from to
______________________________________________________ ______________________________
Address Position Held
______________________________________________________ ______________________________
Job Responsibilities Supervisor’s Name
______________________________________________________ ______________________________
Employer Employed from to
______________________________________________________ ______________________________
Address Position Held
______________________________________________________ ______________________________
Job Responsibilities Supervisor’s Name
______________________________________________________ ______________________________
Employer Employed from to
______________________________________________________ ______________________________
Address Position Held
______________________________________________________ ______________________________
Job Responsibilities Supervisor’s Name
Revised 9/04/08 3
A total of 15 college credits of general education are required by the completion of our program to graduate.
Please check all that you have completed.
All courses must be college level, with the exception of Medical Terminology. All college courses must have
been completed with a “C” average or higher.
Currently Examples of
Course Credits Yes/Year No
Enrolled Acceptable Courses
*Written/Oral English Composition or
Communications - Speech
Minimum 3 credits
*Mathematical College Algebra or
Logical Reasoning - higher
Minimum 3 credits
Arts/Humanities Ethics, Philosophy, or
History
Information Introduction to
Systems Computing or other
computing course
Social/Behavioral Psychology or
Sciences Sociology of any type
Natural Sciences Chemistry or Physics
**Medical Any medical
Terminology terminology class
(college or non-college)
Total 15 minimum
* These are pre-requisites courses (6 credits) that need to be completed prior to starting our program. The
remaining 9 credits may be chosen from the above categories and must be completed before the end of the
program. However, the student cannot take more than two (2) courses from the same category.
** Medical Terminology course can be a college or non-college course. If it is a college course, those credits
can be counted as part of the 15 credits needed.
Do you have previous medical experience? _____ Yes _____ No
Please list medical skills that you possess:
Have you ever worked/volunteered in a customer service role or worked with the public? _____Yes _____ No
If yes, please describe:
Revised 9/04/08 4
PROFESSIONAL CAREER STATEMENTS
State briefly on a separate sheet of paper (Please Type):
1. Why you are interested in a career in Radiologic Technology?
2. Do you have any special reasons for desiring to enter this school?
3. How did you hear about the WellSpan Health Radiography Program?
4. What skills or characteristics (i.e., language skills) distinguish you from other applicants?
PLEASE READ CAREFULLY BEFORE SIGNING
All applicants are considered for admission without regard to race, creed, color, national origin, religion, marital
status, age, sex, sexual preference, sexual origin or disability.
ARRT Ethics Requirements: Students who have been convicted of a felony or misdemeanor may have violated the
American Registry of Radiologic Technologists (ARRT) Rules of Ethics, and may be considered ineligible to sit
for board examinations. Individuals may submit a pre-application form to the ARRT (651-687-0048) at any time
either before or after entry into an approved educational program.
Please Note: a criminal background check will be required if you are accepted into the program.
Permission is hereby given to the WellSpan Health Radiography Program to investigate all pertinent information
concerning my application in order to determine my qualifications for admission. I understand that any willful
misrepresentation or omission of fact contained in this application will be the cause for rejection or dismissal.
_____________________________________ _______________________________________________
Date Signature of Applicant
APPLICATION PROCEDURE
The applicant is responsible for all information, which includes; the completed application, $25.00 dollar non-
refundable application fee, transcript forms/official transcripts, three reference letters, observation form, and
professional career statements. Please send a Money Order or Certified Check for the application fee; Cash
and Personal Checks are not accepted. Make payment payable to Radiography Program. All of the above
information must be received by the WellSpan Health Radiography Program by January 31st. For more
information or questions, please call the school at (717) 812-3599 or e-mail at radiographyprogram@wellspan.org
Please mail to:
WellSpan Health Radiography Program
37 Monument Road
Suite 101
York, PA 17403
Revised 9/04/08 5
WellSpan Health Radiography Program
Observation Form
All applicants are required to observe at least 3 hours at “any” Radiology Department of their choice before the
deadline of applications, which is January 31st. The following must be completed by one of the following
representatives: School Faculty member, Radiology Director, Chief Technologist, or Department Manager
Observational Student: ________________________________________________________________
Name of Hospital: _____________________________________________________________________
Date/Time: ___________________________________________________________________________
________________________________________ ________________________________________
Representative Signature Title
If you would like to shadow at York Hospital, York Hospital Imaging Center, or Gettysburg Hospital and
you are a high school student please have your guidance counselor contact the Human Resource
Department by calling 717-851-1675. If you are a college student or a career change individual you may call
Human Resources directly. Information about the York Hospital Student Shadowing Program is on the
following web site www.wellspan.org under education and research.
If you have any questions please feel free to contact:
WellSpan Health Radiography Program at (717) 812-3599 or Fax at (717) 812-3809
*This form must be returned along with your application by January 31st.
Revised 9/04/08 6
WELLSPAN HEALTH RADIOGRAPHY PROGRAM
GUIDANCE COUNSELOR FORM
If you attended more than one High School, please copy.
Dear Guidance Counselor or Authorized Personnel:
This section must be completed by Applicant
Please indicate the following for ________________________________________
(First, Middle and Last Name)
Maiden Name (If Applicable) __________________________________________
Graduation Year: ____________________________________________________
This section must be completed by Present Guidance Counselor or Authorized Personnel
G.P.A. _________________ (example: 4.0, 3.5. 2.5. etc.)
Algebra Grade (if applicable) ______________ Did not take Algebra _____
Biology Grade (if applicable) ______________ Did not take Biology _____
Name of High School: ______________________________________________________
Present Guidance Counselor or Authorized Personnel Name: _______________________
(Please print name)
High School Phone Number: _________________________________________________
Signature: _____________________________________________ Date: ______________
Please include the school’s grading scale along with this form
If you have any questions please feel free to contact the school at (717) 812-3599. This form must be
completely filled out or the student will not meet the admission requirements of the school. Please send this
form with a copy of the applicant’s original transcript to:
WellSpan Health Radiography Program
37 Monument Road
Suite 101
York, PA 17403
Deadline is January 31st
Revised 9/04/08 7
WELLSPAN HEALTH RADIOGRAPHY PROGRAM
OFFICE OF REGISTRAR FORM
If you attended more than one College, please copy.
Dear Office of Registrar:
This section must be completed by Applicant
Please indicate the following for ______________________________________________
(First, Middle and Last Name)
Maiden Name (If Applicable) ________________________________________________
Graduation Year: __________________________________________________________
This section must be completed by Office of Registrar
G.P.A. _________________ (example: 4.0, 3.5. 2.5. etc.)
Algebra Grade (if applicable) ______________ Did not take Algebra _____
Biology Grade (if applicable) ______________ Did not take Biology _____
Name of College: __________________________________________________________
Registrar’s Name: __________________________________________________________
(Please print name)
College Phone Number: _____________________________________________________
Signature: _____________________________________________ Date: ______________
Please include the school’s grading scale along with this form
If you have any questions please feel free to contact the school at (717) 812-3599. This form must be
completely filled out or the student will not meet the admission requirements of the school. Please send this
form with a copy of the applicant’s original transcript to:
WellSpan Health Radiography Program
37 Monument Road
Suite 101
York, PA 17403
Deadline is January 31st
Revised 9/04/08 8
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