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Diagnostic Medical SonographyProgram ApplicationDate of Application: _________________Name: ___________________________________________________________________________________ Last FirstMI Other names usedSocial Security Number: _______-_______-_______ Email Address: _________________________________ Collin College Student ID: _____________________Home Address: __________________________________________________________________________________________ Street/P.O. Box Number __________________________________________________________________________________________City State Zip CodeTelephone Number: ( ) _______________________College(s) Attended: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________Degree/Certificate Earned (include date earned): ____________________________________________________________________________________________________________________________________________Do you hold any healthcare certifications? If yes, please list certification and expiration date:__________________________________________________________________________________________Have you worked in a healthcare facility for at least 2 years? If yes, please list position, practice/facility name, and contact information for employment verification: __________________________________________________________________________________________Have you completed HPRS 1204 or a patient/health care course? If yes, list course and semester completed: _________________________________________________________________________________________Have you completed HITT 1305 or a medical terminology course? If yes, list course and semester completed: ________________________________________________________________________________________Have you applied to the Diagnostic Medical Sonography program or any other program at Collin College within in the past 5 years?__________ Yes____________ NoIf yes complete the next section. To what program did you apply? ________________________ Status (circle one): Accepted / DeclinedPrerequistes and Core Courses Completed to Date: please list the semester, year, and what college the course was completed at for each course listed below. Indicate “IP” for items in progress. ____________________________________BIOL 1406Biology for Science Majors____________________________________BIOL 2401Anatomy and Physiology I (within 5 years)____________________________________BIOL 2402Anatomy and Physiology II (within 5 years)____________________________________ENGL 1301Composition I____________________________________MATH 1314College Algebra____________________________________PHYS 1405Conceptual Physics____________________________________PSYC 2301General Psychology*(or other Social/Behavioral Sciences course)____________________________________ Humanities / Fine Arts course____________________________________PSB Exam Date or will take on __________By signing below, I agree to the following conditions:The information given in this application is factual. I understand that knowingly submitting false information is subject to a penalty of removal from consideration for the program, or removal from the program. I further authorize the Diagnostic Medical Sonography Program to obtain copies of my transcripts received by Collin County Community College. I have read, and agree to the terms in the Information Packet.__________________________________________________________________________________________SignatureDateCollin College does not discriminate on the basis of race, color, religion, age, sex, national origin, disability or veteran status.Please return the completed application and official transcripts to the Health Sciences Division Office in H201 at the Central Park Campus, 2200 W. University Drive, McKinney, Texas between the hours of 8AM and 5PM, Monday through Friday. Application deadline is November 30th. Application may be emailed to MLChambers@collin.edu. ................
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