DEADLINE:
First Friday in August
(Fall Semester)
Third Friday in November
(Spring Semester)
Which program are you applying for
Please Select
Certified Nursing Assistant (CNA)
Medical Assistant Certificate (MA)
Medical Laboratory Technician (MLT)
Pharmacy Technician
Surgical Technology
Which nurse assisting course are you applying for ?
Please Select
Concurrent Enrollment- high school students
One semester in-person
Seven week hybrid
Name
First Name
Middle Name
Last Name
Name Previously Use
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 at least 16 years of age
Yes
I am subject to a background check and drug screen for clinical time
Yes
I am required to have all vaccines current and submit vaccination records
Yes
Upload Covid-19 Immunization Cards
*
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