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TARRANT COUNTY COLLEGEPrint FormCERTIFICATE IN VASCULAR INTERVENTIONALRADIOGRAPHYApplication for Admission1. Biographical InformationSSN:(No Dashes)TCC ID:Date of BirthLast Name:First Name:Middle Name:Address 1:City:Apt #:State: TXZip Code:Primary Phone:(No Dashes)Secondary Phone:(No Dashes)Primary E-mail Address:MyTCC E-mail:2. Emergency Contact InformationFull Name:Address 1:City:Apt #:State: TXZip Code:Primary Phone:(No Dashes)3. Education InformationHigh SchoolSchool Name:Certificate:Completion Date:School Name:Certificate:From:To:School Name:Certificate:From:To:School Name:Certificate:From:To:College/University - (Include TCC, if applicable)Page 1 of 4
4. Previous Application Information4a. Have you ever applied for an Health Science program at TCC?YesProgram:NoMonthYear5. Background Information5a. Gender:MaleFemale5b. Race:American/Alaska NativeInternationalAsianMultiBlack or African AmericanRace UnknownHawaiian/Pacific IslanderWhiteHispanic/Latino6. Is English your native or first language?YesNo(If no see TOEFL/IELTS information.)I attest that this application to the Vascular Interventional Radiography Program is complete and correct. I understand that bysigning and submitting this application I am not guaranteed a place in this program and that I am only eligible for selectionaccording the terms listed in the information packet. I also understand that by signing the application I am responsible forsubmitting ALL documents and information required for eligibility into this program to the Allied Health Department. I haveread and understand the requirements and procedures for admission into the Allied Health Programs as outlined in theApplication Information Packet.SignatureDateI give permission for TCC to release my student transcript to the Allied Health staff at TCC.SignatureDateSubmit all application materials in person or by mail to:Tarrant County College - TRECAllied Health - Vascular Interventional Radiography245 E. Belknap StreetFort Worth, TX 76102Application materials include:1. Application2. Application Checklist3. Current ARRT license4. Immunizations5. ACLS/BSL CertificationPage 2 of 4
For Office Use OnlyVascular Interventional RadiographyStudent Name:TCC ID:Last nameFirst nameVascular Interventional Radiography Application and ChecklistCurrent ARRT and TMB license copiesCopies of BLS/ACLSGPA (Radiologic Technology))TCC Transcript SignedTOEFL/IELTS (if applicable)Current EmployerInformation SheetHepatitis AHepatitis B Measles, Mumps,RubellaChickenpoxTuberculosisHep A-1Hep B-1MMR-1Varicella-1TBHep A-2Hep B-2MMR-2Varicella-2TB ( )Hep A-THep B-3MMR-TVaricella-TChest X RayTetanus, Diphtheria,PertussisTDaPHep B-TCommentsTCC StaffSignature:Date:StudentSignature:Date:Page 3 of 4
TOEFL/ IELTS InstructionsIf you did not graduate from a high school in the United States or a high school on a US militaryinstallation where English was the primary language used:Provide documentation of graduation from high school from an English speaking country such as Canada(other than Quebec), Great Britain, Australia, New Zealand, South Africa, and Ireland. If graduated fromEnglish speaking high school in a country not listed above in #2, provide official transcripts and anotarized letter from theheadmaster/principal of the high school stating that English was the primary language ofthe courses taught.If English was NOT the primary language of your high school you must provide documentation of proof of Englishproficiency by submitting the results of either of the following:1. TOEFL - iBT- Test of English as a Foreign Language – Internet Based Test - passing score of 83. This is therecommended score to apply for licensure from the Texas BON (Board of Nursing)HYPERLINK http://www.ets.org/toefl/ http://www.ets.org/toefl/2. IELTS – Academic version- International English Language Testing System –IELST Band Score – over all6.5 with a minimum score of 6 in all areas. This is the recommended score to apply for licensure from theTexas BON (Board of Nursing).Page 4 of 4
Vascular Interventional Radiography Application ChecklistPlease check off the following items as they are completed in order to be an eligible candidate for our AlliedHealth Program.1.I have applied to Tarrant County College.2.I have read the information on the TCC website for Vascular Interventional Radiography. I willsubmit my completed application to the Trinity River East Campus (in person or by mail) with my signedapplication materials before the application deadline.TCC - Trinity River East Campus - Allied Health Department245 E. Belknap StreetFort Worth, TX 76012-19013. I have provided current official transcripts from ALL colleges and schools attended to the TCCRegistrar. For transcript submission follow-up, contact the TCC Registrar at 817-515-1051.4. I verify that I have meet the TCC's Texas Success Initiative (TSI) requirements.5. I verify that I all my immunizations required (listed on the website) have been started AND will becomplete no later than the first day of class. PLEASE NOTE: The Hepatitis A and B shots require 6 months to getthe two or three shots.6. I acknowledge that I will be required to pass a Drug Screening and Background check. I alsoacknowledge that these required checks will be administered within 30 days prior to starting the program. If Ifail either of these protocols, I acknowledge that I will be dismissed from the program.7. (If applicable) I have submitted my criminal history evaluation results to the Director of Allied Health.Please use the address listed above for item number 2.8. I acknowledge that I will be required to obtain ACLS and BLS prior to the start of clinic. I alsounderstand that copies of my BLS/ACLS are required as part of the program.By signing below, I verify that I have read and understand that I am responsible for providing, and meeting, thecriteria listed in this document. If it is discovered that any of the information I have provided for the applicationhas be falsified, I will be dismissed from the program.SignatureDatePage 1
2. _ I have read the information on the TCC website for Vascular Interventional Radiography. I will submit my completed application to the Trinity River East Campus (in person or by mail) with my signed application materials before the application deadline. TCC - Trinity River East Campus - Allied Health Department 245 E. Belknap Street
