Institute Of Medical Ultrasound

Application For Admission

APPLICATION FOR ADMISSION

PROGRAM REQUESTED:

Select the diploma program specialty area from the choices below:

START TIME REQUESTED:

A. PERSONAL DATA:

First Name
Middle Initial
Last Name
Date of Birth
Social Security Number
Street Address
Address (/Apt#)
City
State
Zip Code
Home Phone
Additional Phone
Email Address
Emergency Contact
Contact Street Address
Contact Address (/Apt#)
Contact City
Contact State
Contact ZipCode
Contact Home Phone
Contact Additional Phone

B. EDUCATION:(Applicants must have either a bachelor's degree or be a graduate of a single, 2-year allied health program that is patient care related. For additional information, applicants may contact the school by phone.)

Select all that apply:

Bachelor's Degree

Major
Year Graduated
College Attended
College Street Address
Additional Address
City
State
Zip
2yr allied health degree (minimum of 60 semester credits/4 semesters or 84 quarter credits/6 quarters)

Major
Year Graduated
College Attended
College Street Address
Additional Address
City
State
Zip

Have you studied in the following subject matter, either in high school or college? Select any of the following that apply:

Algebra

Communication Skills

General Physics

Biological Science

C. HEALTH

Which of the following best describes your status regarding the Hepatitis B Series of injections that the health department recommends for all health care workers?

I have started or will start the Hepatitis B vaccine prior to registering for any of the Institute of Medical Ultrasound's clinical training courses. I will notify the Institute of Medical Ultrasound upon initiation and completion of the series.

I have previously received the Hepatitis B vaccine series of injections and can provide documents or titer results.

I have decided NOT to receive the Hepatitis B vaccine even though I understand that my clinical training and future profession may expose me to blood or other infectious materials, that NOT receiving the vaccine may seriously limit the Institute's ability to assign me to a clinical training facility, and that limiting my assignment to a clinical training facility may negatively impact my ability to graduate from the program.

D. APTITUDE REQUIREMENTS OF THE PROFESSION

By checking the appropriate boxes, the applicant agrees he/she can demonstrate these basic abilities so he/she can acquire, through our training program, the skills described below.

	Visual Aptitude: possesses the visual skills, either with or without corrective eyewear, that would allow, through our training program, to learn to differentiate among shades of gray, differentiate red, blue and associated shades, identify keys on a keyboard, read doctor's orders, requisitions and medical records, interpret sonograms, assess patient's skill pallor, respiratory distress, etc.

		Auditory Aptitude: possesses the auditory skills, either with or without corrective eyewear, that would allow, through our training program, to learn to hear speech within the normal audible range, discriminate among heart sounds, assess patient respiratory efforts, respond to department emergency procedure instructions, respond to patient requests when they are not facing you.

		Physical Aptitude: Gross Motor: walk, crouch, stand, stoop, reach, push/pull exert up to 50 lbs of force (while transporting, assisting, patients/equipment) Fine Motor: fingering a keyboard, writing legible reports, assembling procedure trays

		Intellectual Aptitude: possesses the intellectual aptitude, that would allow, through our training program, to learn to assess sonograms, differentiate among pathological and sonographic appearances, follow department protocols.

		Emotional Aptitude: demonstrate compassion for patients, cooperate with other staff, respond appropriately during emergencies, remain focused despite potential stressful situations related to the clinical work environment, accept constructive criticism.

		Professional Aptitude: maintain patient confidentiality, demonstrate honesty and integrity, demonstrate punctuality and a professional appearance, use appropriate language with patients, patientâ€™s families and health care providers.

E. ADDITIONAL DOCUMENTS

Additional documents are required prior to finalizing the applicant's acceptance into the program. Links to these forms will be provided with a confirmation email granting provisional acceptance into the program. Additionally, applicants may download these forms from the web site Forms Library.

1.	The application process requires three (3) letters of recommendation, preferably on the reference's letter head, describing the applicant's level of initiative and self-motivation, demonstration of professional behaviors, problem-solving abilities and communication skills.

2.		The application process requires original transcripts from all academic institutions listed in this application.

3.		The application process requires a record of immunizations or titer results for the following: MMR, DPT, and TB.

How did you hear about us?

How do you anticipate financing the education for your new career?

I understand that a $50.00 non-refundable application fee must be submitted with this application before it can be processed.

By submitting this document, I agree, that to the best of my knowledge, the above information is true and correct.

Application For Admission