Individual Referral Training Application

ASSOCIATE DEGREE RADIOGRAPHY APPLICATION A45700 Please mail application to: Hand deliver to: Wake Tech Health Sciences Campus Student Services Building Admissions Office at the Health Sciences Campus 2901 Holston Lane 2901 Holston Lane Raleigh, NC 27610-2092OR Raleigh, NC 27610

This application does not replace the Wake Technical Community College Application for admission. The Wake Tech application must be on file prior to submitting the Radiography application. You must fill this application out COMPLETELY or it will not be processed! NOTE: The address you put on this application is the address that will be used to send your admission decision letter.

PERSONAL INFORMATION : (Please Print Legibly)

Name Address Street State Zip C el l P h o n Home Phone: / e: / Work Phone: / Wake Tech E-mail Address: Admission Requirements Checklist √: Attended an Admissions Information Session: (month) (day) (year) (NOTE: If you have not been enrolled at Wake Technical Community College as Pre-Rad within 1 year prior to entry into the Radiography program, then you must attend another Radiography Information Session prior to the application deadline.) CNA1 – Certified Nursing Assistant 1: Last 4 of Social Security # (Required to check if your CNA1 is current and verify the expiration date. (It must be active, be listed on the North Carolina CNA1 registry by Clinical application deadline and remain current through the beginning of the first RAD course.) The attached CNA1 experience form (40 hours) must be completed and submitted with the application.

*** Meet Minimum Admission Requirements for Reading, English, Math per NC Multiple Measures. (Option only available to NC High School students that have graduated within the last 5 years)

READING: Reading proficiency must be satisfied by completion of any ONE of the following: Please √ ONLY the most current: Minimum score on placement test (SAT, ACT, COMPASS, Accuplacer, or ASSET) RED 090 or DRE 098 with a minimum grade of “C”. College where course was completed: . A college level English composition course with a minimum grade of “C”. College where course was completed: . ENGLISH: English proficiency must be satisfied by completion of any ONE of the following: Please √ ONLY the most current: Minimum score on placement test (SAT, ACT, COMPASS, Accuplacer, or ASSET) ENG 090 or DRE 098 with a minimum grade of “C”. College where course was completed: . A college level English composition course with a minimum grade of “C”. College where course was completed: . MATH: Math proficiency must be satisfied by completion of any ONE of the following: Please √ ONLY the most current: Minimum score of placement test (SAT, ACT, COMPASS, Accuplacer, or ASSET) A college level Mathematics course with a minimum grade of “C”. College where course was completed: . MAT 070 with a minimum grade of “C” and completion of DMA modules (010-050) with a “P”. College where course was completed: . ~2~ CHEMISTRY: Chemistry requirement may be satisfied by completion of any ONE of the following: Please √ ONLY the most current: High School or College Chemistry course with a minimum grade of “C”. HS/College where course was completed: . CHM 090 with a minimum grade of “C”. College where course was completed: . Chemistry Tutorial Unit (ILC) with a minimum grade of “C”. Date completed:

TEAS Scores: All Radiography Clinical applicants must take the TEAS V. 25 points will be added towards the Radiography clinical competitive process for scores of 63% or above.

Test Date(s): Name of school test was taken: NOTE: If you take a section more than once, we will use the highest score you made for that section to calculate your Composite Score. (TEAS must be taken prior to the RADIOGRAPHY (clinical) application deadline.

I want to be considered for: Fall Semester 20 Spring Semester 20 Application Deadline January 31 Application Deadline July 31

NOTE: You MUST submit a new Radiography application for each Radiography pool that you want to be considered. You must also provide any updated transcripts or other applicable information by the application deadline.

Other Coursework Completed: Please provide the information below for all completed equivalent courses from Wake Tech Community College and any other institutions you have attended. Please indicate if you are currently enrolled in a course this semester and at what college and at what school you are taking the course.

ALL OFFICAL TRANSCRIPTS MUST BE TURNED IN BY THE RADIOGRAPHY APPLICATION DEADLINE!!!

Equivalent  if Name of complete Course Credit for: College/Univ d Name & ersity Course # ENG 111 ENG 112 HUM. PSYElective 150 * BIO 163 * MAT 143 *or MAT 152

* This class must have been completed within 5 years from the start of the RAD classes.

I certify that all the information on this application is accurate to the best of my knowledge.

Signature of Applicant Date

Please note that Wake Technical Community College is constantly evaluating the admissions procedures and reserves the right to make changes as the need arises.

WAKE TECHNICAL COMMUNITY COLLEGE Associate Degree Radiography Program Verification of NAI training within 5 years of clinical Radiography Program entry

PART A: (Must be completed by student)

STUDENT NAME/ADDRESS

STUDENT PHONE NUMBER/EMAIL

NAME/ADDRESS OF NURSING ASSISTANT PROGRAM ATTENDED

PROGRAM DIRECTOR/INSTRUCTOR NAME, PHONE NUMBER/EMAIL – to be contacted for verification

YEAR PROGRAM COMPLETED

PART B: (*Not required if attended Wake Tech CC Nursing Assistant Program)

(Must be completed by the NA Program Director/Instructor from programs other than WTCC):

Name of NAI Program Attended

Date completed

Dear Nurse Aide I NA Program Director/Instructor:

This prospective student is being considered for admission to the Radiography program at WTCC. Please confirm his/her satisfactory completion of your Nursing Assistant program. yes no Please verify that the applicant completed a minimum of 40 clinical hours. yes no

Signature Date

WAKE TECHNICAL COMMUNITY COLLEGE Associate Degree Radiography Program Employer verification of 40 hours of work experience as CNA I within 5 years of entering the clinical Radiography Program.* (*Required if student cannot verify 40+ hours of clinical experience during a NAI Program within 5 years of entering the Radiography Program.)

PART A: (Must be completed by student)

STUDENT NAME/ADDRESS

STUDENT PHONE NUMBER/EMAIL

EMPLOYER NAME/ADDRESS

SUPERVISOR’S NAME/PHONE NUMBER/EMAL

DATES OF EMPLOYMENT month year to month year

BRIEF DESCRIPTION OF DUTIES PERFORMED AS NURSING ASSISTANT:

You have my permission to contact my employer below if verification of work experience is needed.

STUDENT SIGNATURE DATE

PART B: (Must be completed by employer)

Dear Employer:

This prospective student is being considered for admission to the Radiography program at WTCC. Please confirm his/her work experience (paid or volunteer) for a minimum of 40 hours as a C.N.A as documented above.

Yes, this person was employed as a C.N.A during the time indicated above and performed the duties described. No, the above description does NOT reflect the dates and duties performed on the job.

Signature Date

Form 1487 R-2 (6-2-16) LW/SS