DEADLINE:
First Friday in August
(Fall Semester)
Third Friday in November
(Spring Semester)
Name
First Name
Middle Name
Last Name
Which Nurse Assisting Course are You Applying For ?
Please Select
Concurrent Enrollment- high school students
One semester in-person
Seven week hybrid
Name Previously Used
Student USU A#
Daytime Phone Number
Please enter a valid phone number.
Evening Phone Number
Please enter a valid phone number.
Cellphone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
Highschool Attended
Email Address - This will be used to contact you about the MA program
example@example.com
Highschool or College GPA
Emergency Contact
Emergency Contact
First Name
Last Name
Emergency Phone Number
Please enter a valid phone number.
I have provided true, complete and correct information on this application.
Yes
I understand I must be >16yrs of age.
Yes
I must pass the pre-admission assessment with >80%.
Yes
I am subject to a background check and drug screen for clinical time.
Yes
Signature
Date
-
Month
-
Day
Year
Date
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