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Cancer Registry Management Certificate Admission Application
Danville Area Community College 2000 East Main St, Danville, Illinois 61832 Telephone 217-554-1678 – www.dacc.edu
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The following is required to complete a succesful application
If have never attended Danville Area Community College, you need to be admitted to the college, use the link below to be admitted:
https://dacc.edu/applicationstudent-information-form
Before being considered for admission into the Cancer Registry Management Program, applicants must meet these criteria:
Any Associate’s Degree or higher
Applicants must have completed FOUR Pre-Requisite Courses prior to program entry. Those include; HITT 115, HITT 101, BIOL 136, and BOFF 140
Official transcripts from all colleges or universities previously attended must be on file with DACC Records Office.
You have to submit transcripts twice. One Unofficial at the end of this application and one Official. Here is how:
At the end of this application you will submit Unofficial or copies of all transcripts, including DACC transcripts.
You also MUST have your Official Transcripts evaluated by our Registrar as well in order to get into the program. You can submit your Official Transcripts using the following link:
https://www.parchment.com/u/registration/33654/institution
Submit by the last Friday in May at noon.
If you have any questions, please contact Kelly Johnson at k.johnson@dacc.edu or by telephone (217)554-1678
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2
Name
First Name
Middle Name
Last Name
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3
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Bolivia
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Brazil
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New Zealand
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Northern Mariana
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Peru
Philippines
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Poland
Portugal
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Russia
Rwanda
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Saint Kitts and Nevis
Saint Lucia
Saint Martin
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Turkey
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Venezuela
Vietnam
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US Virgin Islands
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Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Phone Number
Please enter a valid phone number.
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Email
DACC Email
Personal Email
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DACC Student ID#
Admission into this program is contingent on applying to the college itself. If you are not already a student, please fill out the new student application form. The link can be found at the beginning of this application.
Apply to DACC if not already a student
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Pre-Requisite Courses
Completed at (School Name)
Final Grade
BIOL 136- Anatomy and Physiology 1
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BOFF 140- Medical Terminology
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HITT 115 or BIOL 137- Pathophysiology and Pharmacology OR Anatomy and Physiology 2
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HITT 101- Introduction to Health Information Technology
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BIOL 136- Anatomy and Physiology 1
BOFF 140- Medical Terminology
HITT 115 or BIOL 137- Pathophysiology and Pharmacology OR Anatomy and Physiology 2
HITT 101- Introduction to Health Information Technology
Completed at (School Name)
Row 0, Column 0
Final Grade
Row 0, Column 1
Completed at (School Name)
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Final Grade
Row 1, Column 1
Completed at (School Name)
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Final Grade
Row 2, Column 1
Completed at (School Name)
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Final Grade
Row 3, Column 1
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8
Education Background
Before being considered for admission into the Cancer Registry Management Program, applicants must have a completed an associate degree or higher
Indicate associate degree or higher
Year completed
Completed at
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9
Have you ever been charged with or convicted of a misdemeanor or felony? (This includes court convictions and military courts-martial.)
Answer "Yes" if you have: - Charges or convictions-including those that were stayed, withheld or deferred, set aside, or suspended - Any plea of guilty, Alford plea, or plea of no contest (nolo contendere) -Court conditions applied to your charge-including court supervision, probation, or pretrial diversion -Traffic violations charged as misdemeanors or felonies -Traffic violations that involved drugs or alcohol
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NO
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If yes, please give a complete explanation.
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How did you learn about the Cancer Registry Management Certificate Program at Danville Area Community College?
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PROVIDE UNOFFICIAL COPIES OF ALL COLLEGE TRANSRIPTS, INCLUDING DACC
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All Official Transcripts must be filed and updated with the DACC Records Office
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