Classroom: 4 West Second Street, Lower Level, Riverhead, New York 11901 Mailing Address: 1300 Roanoke Avenue, Riverhead, New York 11901 (631) 548-6173 E-mail: xrayschool@pbmchealth.org APPLICATION FOR ADMISSION Ð DUE MARCH 1, 2023! (CLASS OF 2025) Part I: Information Name: ____________________________________________________________________________________ Street Address: _____________________________________________________________________________ Town: ________________________________________ State: _____________ Zip Code: _________________ Home Telephone #: ________________________________ Cell Phone #: ______________________________ Social Security #: ___________________________________ Application Date: __________________________ Person To Be Contacted In Case of Emergency: ___________________________________________________ Telephone # of Emergency Contact: __________________________________ Relationship: _______________ Have You Ever Been Known By Another Name? _________ YES __________ NO If Yes, What Was The Name? __________________________________________________________________ Are you legally eligible to attend school in the USA as per the Immigration Reform & Control Act? ___________ YES ___________ NO Are you able to perform the duties of a student radiographer as stated in the Technical Standards on page 7 and 8 of the Program Catalog? ___________ YES _________ NO Are you a graduate with the minimum of an Associate Degree from an accredited college/university? If not, please state when your degree will be conferred by the college/university? _____________________ Date of Conferral ___________ YES ___________ NO Have you ever had any previous training in Radiography? ___________ YES ___________ NO Do you have any previous healthcare experience? ___________ YES ___________ NO A ÒNoÓ response does not negate your admission to the school! What is your current email address? ___________________________________________________________ Please PRINT CLEARLY ANY CHARACTERS IN THE EMAIL ADDRESS! WE WILL CONTACT YOU USING YOUR EMAIL ADDRESS SUPPLIED UPON APPLICATION! Part II: Education Section College/University #1 (Most Recent Please!) Name of Institution: _________________________________________________________________________ Address of Institution: _______________________________________________________________________ Town, State and Zip of Institution: ______________________________________________________________ Attended From: __________________________ Attended To: _____________________________________ Degree/Certificate Awarded: __________________________________________________________________ -------------------------------------------------------------------------------------------------------------------------------------------------- College/University #2 Name of Institution: _________________________________________________________________________ Address of Institution: _______________________________________________________________________ Town, State and Zip of Institution: ______________________________________________________________ Attended From: __________________________ Attended To: _____________________________________ Degree/Certificate Awarded: __________________________________________________________________ -------------------------------------------------------------------------------------------------------------------------------------------------- High School/GED Certificate Name of Institution: _________________________________________________________________________ Address of Institution: _______________________________________________________________________ Town, State and Zip of Institution: ______________________________________________________________ Attended From: __________________________ Attended To: _____________________________________ Did you graduate/complete the requirements for the diploma/certificate? _____________________________ ***PLEASE CONTACT ALL EDUCATIONAL INSTITUTIONS TO HAVE YOUR OFFICIAL TRANSCRIPTS FORWARDED TO THE FOLLOWING ADDRESS: Peconic Bay School of Radiologic Technology 1300 Roanoke Avenue, Riverhead, New York 11901 Riverhead, New York 11901 Attention: Frank A. Zaleski, LMSW, MBA, BS RT ( R ), Program Director Part III: Employment Section Employer #1 (Most Recent) Name of Employer: __________________________________________________________________________ Address of Employer: ________________________________________________________________________ Town, State and Zip of Employer: ______________________________________________________________ Employed From: ____________________________ Employed To: ______________________________ What Is/Was Your Position? ___________________________________________________________________ -------------------------------------------------------------------------------------------------------------------------------------------------- Employer #2 Name of Employer: __________________________________________________________________________ Address of Employer: ________________________________________________________________________ Town, State and Zip of Employer: ______________________________________________________________ Employed From: ____________________________ Employed To: ______________________________ What Was Your Position? ___________________________________________________________________ -------------------------------------------------------------------------------------------------------------------------------------------------- Employer #3 Name of Employer: __________________________________________________________________________ Address of Employer: ________________________________________________________________________ Town, State and Zip of Employer: ______________________________________________________________ Employed From: ____________________________ Employed To: ______________________________ What Is/Was Your Position? ___________________________________________________________________ -------------------------------------------------------------------------------------------------------------------------------------------------- Part IV: Professional/Academic References (Please-no relatives or friends!) 1. Name: __________________________________ Relationship to Person: ______________________ Telephone #: _____________________________ 2. Name: __________________________________ Relationship to Person: ______________________ Telephone #: _____________________________ 3. Name: __________________________________ Relationship to Person: ______________________ Telephone #: _____________________________ Part V: Requirements I have enclosed the essay component of the application utilizing the ÒPERSONAL ESSAY FORM ATTACHMENTÓ answering the questions: ÒOut of all the healthcare professions to choose from, why are you choosing Radiologic Technology at Peconic Bay Program of Radiologic Technology?Ó and then, ÒPlease describe any lessons, hardships, challenges, or opportunities that resulted from the global COVID-19 pandemic. In particular, describe how these insights have informed your motivations and preparation for our program in areas of academics, employment, volunteer service and/or other clinical experiences you may have.Ó ___________ YES ___________ NO I have enclosed the application fee of $100.00 made payable to: ÒPeconic Bay Medical CenterÓ CERTIFIED BANK CHECK ____________ ___________ YES ___________ NO PLEASE NOTE THAT YOU CANNOT SCHEDULE YOUR ENTRANCE EXAM OR TAKE YOUR ENTRANCE EXAM UNLESS WE HAVE RECEIVED THIS APPLICATION TO THE SCHOOL! THERE ARE NO EXCEPTIONS! All of the answers given in this application are true and complete to the best of my knowledge. If I am accepted into the Peconic Bay School of Radiologic Technology, I agree to abide by the rules, policies, and regulations set forth by the school and by Peconic Bay Medical Center. Signature: ___________________________________________________ Date: ______________________ *A CERTIFIED BANK CHECK is a check that you receive from your bank. A certified check is a personal check guaranteed by the check writerÕs bank. The bank verifies the account holderÕs signature and that he or she has enough money to pay, then sets aside the check amount for when itÕs cashed or deposited.* PLEASE NOTE! You will not be permitted to sit for the Entrance Exam without this form being completed and submitted FIRST! Peconic Bay School of Radiologic Technology Application for Admission Ð Updated September 2022 WE ARE NOT RESPONSIBLE FOR A LOST APPLICATION IN THE MAIL!!! 2