Information about http://www.kumc.edu/allied/documents/sah_application_letter_jan2008.pdf
INSTRUCTIONS: …
Tags: academic program, allied health, application fee, cert, clinical laboratory science, diagnostic ultrasound, health information management, incomplete applications, initials, kansas city kansas, ku school, management bs, office of student affairs, osrr, program selection, rainbow boulevard, respiratory care, science bs, term residency, undergraduate application,Pages: 2
Language: english
Created: Wed Jan 23 13:01:00 2008
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INSTRUCTIONS: FOR OSRR ONLY: ENTERED FROM KUMC
Please complete all fields, sign,
and return completed application STUDENT NO. SCHOOL/LEVEL
with $60.00 application fee to:
KU School of Allied Health YEAR/TERM RESIDENCY
Attn: Office of Student Affairs
Mail Stop 2007 DATE ENTERED INITIALS
3901 Rainbow Boulevard
Kansas City, Kansas 66160 UNDERGRADUATE APPLICATION
PLEASE TYPE OR PRINT CLEARLY: UNSIGNED OR INCOMPLETE APPLICATIONS WILL BE RETURNED
Part Program Selection 2. Please select the Academic Program to which you are applying
A · Please complete all fields Note: Some Programs may require an additional application specific to that Department
Clinical Laboratory Science (BS) Respiratory Care (BS)
1. Admission requested for semester: Cytotechnology (BS) Respiratory Care (BS for RRTs)
Fall Health Information Management (BS) Diagnostic Cardiac Sonography (certificate)
Health Information Management (BS for RHIAs) Diagnostic Ultrasound & Vascular Tech. (certificate)
Spring Of Year: __ __ __ __
Occupational Studies (BS) Nuclear Medicine Technology (certificate)
Summer Special Student (non-degree)
Part Personal Information
B · Please complete all fields
3. FULL NAME: _______________________________ ______________________ ___________________________________________
First Middle Last
4. MAIDEN NAME: ___________________________ ______________________ ___________________________________________
Or other names under which First Middle Last
your records might be found
5. PRESENT ADDRESS: ___________________________________________ _____________________________ __ __ _____________
Street City State Zip Code
( __ __ __ ) __ __ __ __ __ __ __ ______________________________________________
Phone E-mail Address
6. PERMANENT HOME ___________________________________________ _____________________________ __ __ _____________
Or that of a person who will always Street City State Zip Code
know how to find you
( __ __ __ ) __ __ __ __ __ __ __ ______________________________________________
Phone In what Kansas COUNTY is your home?
7. For purposes of reporting and analysis, KU is asked to provide student counts by state and county of origin. Please list the city, state, zip
code, and county of what you consider your hometown and state.
HOMETOWN: _____________________________ __ __ _____________ _________________________________
City State Zip Code County
8. DATE OF BIRTH: __ __ / __ __ / __ __ __ __ PLACE OF BIRTH:____________________________ Soc. Sec. # __ __ __ - __ __ - __ __ __ __
Month Day Year (State or Country) Social security number and student status data may be provided
to other state agencies for use in detection of fraudulent or illegal
claims against State monies.
9. Are you a resident of the State of Kansas? YES NO
If "yes" when did you begin living continuously in Kansas? __ __ / __ __ / __ __ __ __
MM DD YYYY
If "yes", where? ___________________________________________ _____________________________ __ __ _____________
Street City State Zip Code
10. Last year, did anyone claim you as a dependent for income tax purposes? YES NO
If "yes," who? _____________________________________________ _____________________________________________
Name Relationship to you
_____________________________________________ _____________________________ __ __ _____________
Street City State Zip Code
Please continue application on next page
The University of Kansas is an Equal Opportunity Employer. In compliance with federal government regulations under Titles VI and IX of the Civil Rights Act,
the University must collect data on the race and gender of its applicants. YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION. When received, this
section is separated from the application along the dotted line above, and is not forwarded to the department admissions officer. If you choose to complete the
section, this information will remain in the Dean's Office for statistical reporting purposes only and will not be used in the admissions process.
Gender: Female Male
Race/Ethnicity: American Indian/Alaskan Native Asian/Pacific Islander Black (not of Hispanic origin)
Hispanic White (not of Hispanic origin) Other (please specify): ________________________________
Part Academic and Experience Record
C · Please complete all fields
11. Are you a CITIZEN of the United States of America? YES NO
If answer is NO: Have you been granted Immigrant or Permanent Resident status by the U. S. Immigration & Naturalization Service? YES NO
If NO, indicate type of VISA: __________________________________ If YES, attach a copy of your Alien Registration card to this form.
12. Are you a KU employee or a dependent of one? YES NO
13. Are you a member of the U.S. Armed Forces or a dependent of a member? YES NO
If "yes" is the duty station in Kansas? YES NO
14. Will you or your parents have moved to take a job in Kansas before you enter KU? YES NO
15. HIGH SCHOOL: __________________________ CITY/STATE: _________________________ GRADUATION YEAR: __ __ __ __
16. Have you ever attended, or are you currently attending, the University of Kansas?
NO YES if yes, please indicate dates attended (mm/yy): __ __ / __ __ to __ __ / __ __
KU Student Identification No.: ________________________________________________
17. List below or attach complete information concerning the colleges or universities you have attended, beginning with latest, and
indicate the one from which you received, or expect to receive, your degree. Include graduate work, if applicable. Please show overall
undergraduate Grade Point Average where indicated (A=4.0).
Name and Location of College/University Dates of Attendance (mm/yy) Major Degree GPA
___________________________________________ From __ __ / __ __ to __ __ / __ __ ________________________ ______________ __.__
___________________________________________ From __ __ / __ __ to __ __ / __ __ ________________________ ______________ __.__
___________________________________________ From __ __ / __ __ to __ __ / __ __ ________________________ ______________ __.__
OVERALL Undergraduate Grade Point Average = __.__
18. List below or attach information concerning full time employment (including military service). Begin with the most recent:
Description of Employment Company or Institution Location Inclusive Dates of
Employment
__________________________________ _______________________________________ ________________________ _______________________
__________________________________ _______________________________________ ________________________ _______________________
__________________________________ _______________________________________ ________________________ _______________________
Part References and Signature
D · Please complete all fields
19. List below the names of three people, including recent instructors, whom you have asked to send reference forms regarding your
qualifications. The reference forms should be sent directly to the department to which you are making application.
Reference 1 Reference 2 Reference 3
Name ____________________________________ ____________________________________ ____________________________________
Position/Title ____________________________________ ____________________________________ ____________________________________
Address ____________________________________ ____________________________________ ____________________________________
____________________________________ ____________________________________ ____________________________________
20. Signature of Applicant X ______________________________________________________________ Date of application ___________________
Please direct requests for disability accommodation to the EO/Disability Specialist: 913-588-1206 (Voice) or 913-588-7963 (TDD). Persons with speech or hearing
impairments who wish to contact the university may access the Kansas State Relay at 800-766-3777.
APPLI CANT: D O N O T WR I T E B E L O W T H I S L I N E
Departmental Recommendation Degree sought _________________________________________ Major Code # _____________________
· For Internal Use Only Major field ____________________________________________ Department _______________________
Deficiencies or remarks: _______________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
We recommend admission to the program indicated above. YES NO Date: ________________________
Signature of Departmental Representative: ___________________________________________________________________