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DIAGNOSTIC MEDICAL SONOGRAPHY PROGRAM APPLICATION (CARDIAC CONCENTRATION)

(FORM A)

Non-Discrimination Policy:

Kaiser Permanente is committed to upholding all federal and state laws that preclude discrimination

on the basis of race, gender, age, religion, national origin, marital status, sexual orientation, disabilities or veteran’s status.

I certify to the best of my knowledge the information provided in this application is accurate and complete. I understand that if this information or any other information upon which my admission is based is discovered to be inaccurate or incomplete, the school may rescind my admission. If admitted, I agree to abide by the school’s policies including, but not limited to, those contained in the KPSAHS Catalog and this application. I acknowledge that all submitted official transcripts will become property of the school and will not be forwarded to another institution or returned to me.

Please check all that apply. I have currently or previously applied for the following KPSAHS Programs:

Check

Year(s)

Radiography Day Program Radiography Evening/Weekend Program Diagnostic Medical Sonography Program – General Diagnostic Medical Sonography Program – Cardiac Radiation Therapy Program Nuclear Medicine Program

All applicants must sign and date application:

Signature

Date

Application Cover Sheet, Rev: 12/04, 1/05, 10/05, 9/06, 3/07, 3/08, 9/09, 02/11, 3/11, 6/11

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