Transcript Review

Personal Information
Name * Required
First Last
Mailing Address (no PO Box) * Required
Street Address Address Line 2 City State ZIP Code
Main Phone Number * Required
Email Address * Required
Date of Birth * Required
MM slash DD slash YYYY
Age * Required
Sex
Desired Start Date * Required
Month
Year * Required
Year
Student Type * Required
- Local Student (Within 90 miles of Spanish Fort, AL)
- Distance Student
Previous Medical or Allied Health Training (NOT REQUIRED FOR ENTRY INTO PROGRAM)
Do you have any Medical or Allied Health Training
- Yes
- No
If Yes, Check all that apply and list registry/license # if applicable
- X-Ray
- Nursing (RN/LN)
- CT
- Cert Nursing Asst.
- Mamography
- Other (List)
X-ray Registry/License Number
Nursing (RN/LPN) Registry/License Number
CT Registry/License Number
Cert. Nursing Asst. Registry/License Number
Mamography Registry/License Number
Other Medical Training Information
Name of Institution and Dates Attended
Do you have previous Ultrasound experience? * Required
- Hands On
- Observation Only
- None
If Yes, How much Ultrasound Experience

Educational Information
Have you graduated from an accredited high school or received your GED? * Required
- Yes
- No
Junior College/College/Post-secondary/Military Education * Required
Please list below all colleges, universities, and postsecondary community, junior, and technical colleges previously attended. Any schools listed below, will require submission of OFFICIAL transcripts to complete your application.
Name and Location of School Dates Attended Did you Graduate? Cert/Diploma/Degree Awarded? Overall GPA
Upload Transcripts * Required
You MUST upload a transcript showing you meet the educational requirements to enroll in this program in order to complete this application.
Drop files here or
Accepted file types: pdf, Max. file size: 512 MB, Max. files: 4.

IUD Clinical Site Preference Form
Distance Applicants ONLY
Instructions: The One Year Program requires a great deal of clinical exposure. To qualify and complete the One Year Program as a distance student, you must have a viable clinical site to use located near you or you must be willing to relocate to an available clinical site. If you are applying as a distance student, please fill in the information below.
Anticipated/Desired Start Date
MM slash DD slash YYYY
In which City, State do you plan on completing your clinical requirements? (First Choice)
If the above listed city is not a major city in your state, please list the closest major city and the distance from you. (Second Choice)
If the above listed city is not a major city in your state, please list the closest major city and the distance from you. (Third Choice)
Please list, in order of preference, the top hospitals/clinics (Name, city, state)(Up to 5) in your area you would like to use for your clinical site during the One Year Program.
If we do not have a particular clinical site in your area or are unable to secure a clinical site in your area, are you willing to relocate to an area where we do have clinical sites in order to be accepted into the One Year Program?
Comments
This field is for validation purposes and should be left unchanged.

Personal Information

Name and Location of School	Dates Attended	Did you Graduate?	Cert/Diploma/Degree Awarded?	Overall GPA