MLH School of Radiologic Technology Application

Instructions

Complete the application form. The application deadline is January 15.
Submit the $35 nonrefundable application fee.
Please choose three people who will serve as personal references. Ask them to submit letters of recommendation to Cristi Engel at cengel@marylanning.org.
Review the technical standards and complete the technical standards portion of this form.
Request all high school and postsecondary transcripts to be mailed or submitted to the Mary Lanning Healthcare School of Radiologic Technology. The deadline for submitting supporting documents is February 1.
Please contact the MLH School of Radiologic Technology if you have questions at 402-461-5177 or Cristi Engel, Program Director, at cengel@marylanning.org.

Last name

First name

Former (maiden) name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Last four digits of SSN#

Educational background (Please include all high schools and colleges or universities attended, dates of graduation and degrees received (if any).

Grade transcripts

It is the applicant's responsibility to provide high school and college transcripts (including the current semester) to the MLH School of Radiologic Technology.

References

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Write a paragraph stating your reasons for pursuing the field of radiologic technology.

Have you ever been convicted of a felony? (Felony and misdemeanor convictions, regardless of resolution, may cause a student to be ineligible to take the national certification exam given by the American Registry of Radiologic Technologists. If you have any questions regarding your eligibility, please contact us for more information.

Have you ever job shadowed? This is highly encouraged.

If you have job shadowed, please indicate the location and length of experience.

Technical standards

If you had sufficient training, would you be able to perform the common tasks of a radiographer such as manipulating equipment, evaluating radiograph, processing radiographs, etc.?

Comments

If you had sufficient training, would you be able to perform basic patient care procedures such as lifting, transferring and assisting patients?

Comments

If you had sufficient training, would you be able to perform quick and effective emergency procedures such as cardiopulmonary resuscitation?

Comments

Are you able to communicate orally and in writing and receive communication in order to assess the patient and record information?

Comments

Are you able to withstand the physical and psychological rigors of radiologic technology training, including long classroom and clinical hours and strenuous physical activities? Consistent attendance is mandatory due to the nature of this program?

Comments

Please read carefully and sign below.

I certify that the information on this application is complete and accurate to the best of my knowledge. I understand that withholding information or giving false information may make me ineligible for admission and enrollment. I release from all liability or damage those people, agencies or organizations that may furnish information in connection with my application for admission. If accepted, I agree to read and abide by all hospital and school policies and procedures.

Signature

Date of signature

Payment for your order

School of Radiologic Application fee

$35.00 Quantity
Item subtotal:

Total

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

MLH School of Radiologic Technology Student Application

Instructions

Grade transcripts

References

Technical standards

Please read carefully and sign below.

Payment for your order*

Payment for your order