College Application for the Medical Assistant Program

Completing the application neither guarantees admission to the degree program, nor obligates you to the college.

Please complete all sections of the Application. Your responses will be kept private and secure.
(Personal information should match government issued ID)

There is a non-refundable processing fee of $100.

You must sign your form, so that it will be complete, Thank you!

Personal Information

Program Of Interest

Medical Assistant

Promo Code

(if applicable)

Legal Last Name *

First *

MI

Social Security Number *

Last 4 Digits Only.

Date of Birth *

Home Address *

City *

State *

Zip Code *

Primary Phone *

Secondary Phone

Do you have a different Mailing Address? *

Yes

No

Mailing Address

City

State

Zip Code

Email Address *

Enter Email

Sex Assigned at Birth * Sex Assigned at Birth

Please fill in your Self Identifcation

Are you 18 years of age or older? *

Yes

No

If under 18 please provide information on Parent or Guardian

Parent/Guardian Last Name *

First *

MI *

Parent/Guardian Address

City

State

Zip Code

Parent/Guardian Phone

Have you ever been adjudicated guilty or convicted of a misdemeanor or felony? *

Yes

No

Have you ever been convicted of any drug related offense? *

Yes

No

please explain below:

Citizenship

Citizenship Buttons

US Citizen

US Dual Citizen; please specify other country of citizenshipUS Dual Citizen; please specify other country of citizenship

US National

US Permanent Resident

US Refugee or Asylee

Radio Button

Other Citizenship (Non-US) Other Citizenship (Non-US)

What country are you a citizen of?

Demographics

The questions in this section, while helpful to us, are entirely optional, and you are welcome to move on without answering them.

Are you Hispanic or Latino?

Yes

No

Regardless of your answer to the prior question, please indicate how you identify yourself. (Select one or more)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Previous Education

High School: *

State: *

Graduated? *

Yes

No

Mo/Yr: *

format: 11/2014

College/s Attended:

State:

Graduated?

Yes

No

Mo/Yr:

format: 11/2014

College/s Attended:

State:

Graduated?

Yes

No

Mo/Yr:

format: 11/2014

Are you currently taking any college coursework at a college?

Yes

No

Course Name/s:

Financial Aid

Will you be a candidate for financial aid?

Yes

No

Have you received financial aid from an institution before?

Yes

No

School Name

City

State

School Name

City

State