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Enrollment Eligibility Review Form
Thank you for your interest in the Radiologic Technology Program Shore Medical Center. Please complete the following information to determine your eligibility for enrollment.
14
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1
First & Last Name
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First Name
Middle Initial
Last Name
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2
Phone Number
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(609) 555-2678
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3
Personal E-mail Address
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4
Re-Type E-mail Address
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example@example.com
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5
How did you first hear about our program?
*
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6
Are you currently, or have you been in the past, a student of Atlantic Cape Community College?
*
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YES
NO
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7
If you have a college degree, indicate type:
*
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If you do not have a degree select N/A
Associate Degree
Bachelor Degree
Master Degree
N/A
Other
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8
If you have a college degree, identify the university/college and major:
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9
Have you taken the ATI Test of Essential Skills (TEAS)?
*
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YES
NO
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10
If yes, what was your ATI TEAS test score?
ie. 58.7%
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11
If you have a copy of your ATI TEAS Test Transcript, please upload a copy here.
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ATI TEAS Test Transcript
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12
Please check off the ONLY the courses you've COMPLETED
*
This field is required.
(See additional options to check if you haven't completed any or all.)
I have completed English Composition I
I have completed College Algebra or Precalculus
I have completed Anatomy & Physiology I
I have completed Anatomy & Physiology II
I have not yet completed any of these courses
I am currently enrolled in one or more of these courses
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13
If you are CURRENTLY ENROLLED in a pre-requisite course(s) please mark which one(s).
*
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Select N/A if this does not apply to you.
English Composition I
College Algebra or Precalculus
Anatomy & Physiology I
Anatomy & Physiology II
N/A
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14
Select the grade you received in the following COMPLETED course(s):
*
This field is required.
If you did not complete this course yet, select N/A
Please Select
A+
A
A-
B+
B
B-
C+
C
Other
N/A
Please Select
Please Select
A+
A
A-
B+
B
B-
C+
C
Other
N/A
English Composition I
Please Select
A+
A
A-
B+
B
B-
C+
C
Other
N/A
Please Select
Please Select
A+
A
A-
B+
B
B-
C+
C
Other
N/A
College Algebra or Precalculus
Please Select
A+
A
A-
B+
B
B-
C+
C
Other
N/A
Please Select
Please Select
A+
A
A-
B+
B
B-
C+
C
Other
N/A
Anatomy & Physiology I
Please Select
A+
A
A-
B+
B
B-
C+
C
Other
N/A
Please Select
Please Select
A+
A
A-
B+
B
B-
C+
C
Other
N/A
Anatomy & Physiology II
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