Holy Cross Hospital
Print    Email
Decrease (-) Restore Default Increase (+)

Radiologic Tech Admission Application
* Indicates required information
First Name * 
Middle Name 
Last Name  * 
Email Address * 
Street Address  * 
City * 
State * 
Zip * 
Phone Number * 
Age * 

Education  
High School  
Location of School  
Years Attended 
Did You Graduate? 

Degree & Diploma Received 
College 
Location of School  
Years Attended 
Did You Graduate?  

Degree & Diploma Received 
Other  
Location of School 
Years Attended 
Did You Graduate? 

Degree & Diploma Received 
Are any of your education records retained under another name? * 

If YES, please list name 
Character References 
Give full name and addresses of individuals who can attest to your integrity, intelligence and personality. Do not include relatives. You may include former employers, teachers, guidance counselors, friends, associates, or clergy.  
Three references are required.  
Reference #1 Name * 
Reference #1 Address * 
Reference #1 City/State/Zip Code * 
Reference #1 Phone Number 
Reference #1 Email 
Reference #2 Name * 
Reference #2 Address * 
Reference #2 City/State/Zip Code * 
Reference #2 Phone 
Reference #2 Email 
Reference #3 Name * 
Reference #3 Address * 
Reference #3 City/State/Zip Code * 
Reference #3 Phone 
Reference #3 Email 
Have you ever been convicted of a crime? (optional) 

Note: If yes, contact the ARRT, it may prohibit you from siting for the ARRT Registry Exam. 
All applicants are subject to a criminal background check prior to enrollment. 
I hereby certify that the facts set forth in the above application are true and complete to the best of my knowledge. I understand that, if accepted, falsified statements on this application shall be considered sufficient for dismissal from the school.  
I also understand that admission to the Program constitutes adherence to all Hospital and School policies and regulations. 
If selected for the School of Radiologic Technology, I agree to have a medical examination at my own expense before admission /enrollment. 
Electronic Signature  * 
Date * 
Authentication * 

If the challenge words are too difficult to read, click here to refresh.
 

It is the policy of Holy Cross Hospital to provide equal opportunities to prospective and current employees solely on the basis of individual qualifications, and merit, without regard to race, religion, age, sex, national origin, or handicap and in full compliance with all Federal and State Laws.  The School of Radiologic Technology observes and complies with the institutions policy statement.
Site Map    |    Contact Us    |    Notice of Privacy Practices    |    Legal Statement
©  2012 

Holy Cross Hospital | 1500 Forest Glen Road, Silver Spring, MD 20910 | 301-754-7000