Radiation Therapy Program Application – University of St. Francis

Personal Information

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Phone Number *

Alternate Phone Number

Email *

Ethnicity

*Optional

Education

High School Attended *

High School Start Date/End Date *

Technical or Professional School Attended *

Technical or Professional School Attended Start Date/End Date *

Additional Education

Additional Education Start Date/End Date

Academic References

Please list persons not related to you-- for example, professors, program directors or instructors. *At least two references should come from instructors.

Reference #1

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Relationship *

How long have you known this person? *

Reference #2

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Relationship *

How long have you known this person? *

Reference #3

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Relationship *

How long have you known this person? *

Current/Formal Employment

#1 Place of Employment *

Start date/End Date *

Employer Address *

Address Line 1

Address Line 2

City

State

Zip Code

Employer Phone *

#2 Place of Employment *

Employer Address *

Address Line 1

Address Line 2

City

State

Zip Code

Employer Phone *

Personal Information

Please describe why you have chosen radiation therapy as a career, and briefly describe your short-term and long-term career goals. *

Please describe any related extracurricular activities and/or prior health care experience. *

Agreement *

Check to Agree to Applicant Statement

By checking the box above, I understand that any false statements made as part of this application, will be considered as sufficient cause for application disqualification. I also grant permission to the authorities of this school to investigate any references, and I release the school from any and all liability resulting from such investigation. I consent to any and all medical examinations required by the school to be considered for program admission. Upon completion of the program, I authorize the release of any academic performance information as a student in the program to potential employers. Admission to the University of St. Francis School of Radiation Therapy is granted without regard to race, color, religion, gender, age, disability or national origin.