Diagnostic Imaging Training and Education - The Institute for Advanced Clinical Imaging

The Institute for Advanced Clinical Imaging

Application for Student Registration

To apply online, please complete and submit the following form.

Please Note: All Applications must be accompanied by the $100 course deposit in order to be considered for enrollment. If you are not accepted or the course is cancelled, you will be notified and a full refund will be issued.

Please provide the following information:
* Indicates Required Field

1.) Demographics

Name:

* First Name

* Last Name

Address: * Address2: * City, State, ZIP

* City

* State

* ZIP Code

Home Phone: *

(###)

###

####

Work Phone:

(###)

###

####

Email: * Date of Birth (mm/dd/yyyy)*

2.) Employment

Status:

Unemployed

Full-Time

Part-Time

Student

Place of Employment:

ARRT/ARDMS Registered *

Yes

Eligible?

Certificate # (if registered):

3.) Education History

Education History	School Name	Dates Attended	Year Graduated	Degree Completed

High School
Voc/Tech School
College
College
College

4.) Program

Program of Interest:

Schedule:

YOUR PRIVACY: The Institute for Advanced Clinical Imaging maintains a high level of confidentiality. We do not share information with any other organization and will treat clients' personal information with care.

Student Information