Radiation Protection Certificate Program Application Form

Queensborough offers the opportunity to earn a certificate in radiation protection in two semesters with embedded, paid hands-on experience at a National Lab. The Radiation Protection Certificate Program is connected to an Associate’s Degree in Science and will prepare students for technician roles in nuclear safety, radiation protection, and health physics and potential employment at the National Lab. Students are required to enroll in two radiation protection courses in chemistry, attend program events and give presentations on their research activities in order to receive the full stipend and benefits. Full-time associate degree students who are U.S Citizens or Permanent Residents are eligible to participate.

* Required

Name*

First Name

Last Name

QCC Email Address*

Alternate Email Address*

Phone Number*

Mailing Address for Receiving Stipend Checks*

Address Line 1

Address Line 2

City

State

ZIP Code

CUNYFirst ID*

This is the 8-digit number found on your Student ID card

Class Status*

Freshman (0 - 29.9 credits) Lower Sophomore (30 - 44.9 credits) Upper Sophomore (45 - 55.9 credits)

Citizenship Status *

U.S Citizen U.S. Permanent Resident (Green Card Holder) Neither a U.S citizen nor permanent resident

Major at QCC*

Choose

Current GPA*

Total number of registered credits for the upcoming semester*

Less than 12 12 More than 12

Unofficial Transcript*

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Please indicate your availability at the following times to aid in scheduling workshops/classes*

Tuesdays 10 AM - 12 PM Tuesdays 1 PM - 3 PM Wednesdays 12 PM - 2 PM (Free hour) Fridays 10 AM - 12 PM Fridays 1 PM - 3 PM

Other:

Select all that apply

Availability for $6,500.00 paid hands-on internship at the National Lab*

Mini-semester: January 6-10, 2025(one week) Summer Internship: June 9 - August 8, 2025(ten weeks)

Other:

Select all that apply

Expected Graduation Date*

Date of Birth

MM/DD/YYYY

Current gender identity*

Male Female Transgender Gender variant/non-conforming Not listed Prefer not to answer

Please indicate race and ethnicity*

White Black of African American Asian American Indian and Alaska Native Hispanic, Latino, or Spanish origin Hawaiian/Pacific Islander Prefer not to answer

Other:

Check all that apply

Do you participate in any undergraduate research projects/programs?*

Do you receive Pell Grant funds?*

Yes No

Applicant Essay Part 1: Why are you interested in the Radiation Protection Certificate Program*

Write an essay or personal statement (of at least 250 words) describing your interest in the program. You may include experience from courses completed or in progress which includes laboratory experience. Please mention past research experience(s) if any and what motivates you to participate in this program

Applicant Essay Part 2: Career Goals*

Write a short paragraph describing your career goals. You may include the school you plan to transfer to after QCC and what degree(s) you plan to complete there.

Student Photo Release

I give permission/I do not give permission to the Program I am accepted into to use photographs (whether still or motion) for publicity regarding this program.*

Type full name of student

Signature*

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Date*

Radiation Protection Certificate Program Application Form

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