Health Information Management Application

Important: Please read Application Instructions before completing.

I do hereby attest that I have read the entire "Application Instructions" and realize that failure to follow these instructions will jeopardize my application to the program. Yes
Associate of Science Degree: Radiography (January 15)
Bachelor of Science Degrees: Advanced Clinical Concentration for Radiographers- Applicants must be ARRT eligible radiographers Diagnostic Medical Sonography (January 15) Radiation Therapy (January 15)
University ID Number: *
Email:
First Name: *
Middle Initial:
Last Name: *
Current Address: *
Street address Address line 2 City State/Province/Region Postal/Zip code Country
Home Phone: - Area Code - Prefix Line Number
Work Phone: - Area Code - Prefix Line Number
Cell Phone: - Area Code - Prefix Line Number
Emergency Phone: - Area Code - Prefix Line Number
Emergency Contact:
High School you attended:
Year of High School or GED completion :
College(s) you attended:
Departure from College (yyyy):
No. of College Credits Attained:
Completed College Degree(s):
If applying to the AS/RHIT to BS/HIA Program, I have completed an associates degree in health information and have a current RHIT credential earned within the last seven years: Yes No
I do hereby attest that my application to the program(s) identified is true and correct to the best of my knowledge for the year:
How did you first learn about this profession?: Friend/Relative in the profession Career/Fair presentation High school teacher/counselor Other
Other:
What contributed most to your final decision?: Friend/Relative in the profession Career/Fair presentation High school teacher/counselor Other
Other: