Radiography Program Application

Radiography Program Application

Associate Degree

Galveston College Radiography Program has a selective admissions process. This process is non-discriminatory on the basis of race, color, national origin, gender, age, qualified disability, marital status, veteran’s status, or sexual orientation in admissions to the program.

Note: It is the student’s responsibility to provide the program director written notification of any changes in contact information.

Please complete the form below for application to the Radiography Program. Answers to all items are required. If a question does not pertain to you, simply put NA for the response.

 

Student ID Number:

Application date:

Semester applying for:

Year:

Last Name

First Name

Middle/Other Name

Mailing Address

City

State

Zip Code

Phone Number

Email

Date of Birth (may require documentation)

Last 4 digits of SS#:


Please list academic institutions you attended and received terminal awards, degrees, and/or certifications.

Institution:

Terminal awards, degrees, and/or certifications:

GPA:


I understand that falsifying any information on the application form may result in my application being denied and/or dismissal from the program.

Contact

Daniel Fink
Radiography Program Director

Phone

409-944-1444

Fax

409-944-1511

Email