UC Blue Ash Micro-Credential Form

UC Blue Ash Micro-Credential Form
Which Micro-Credential are you pursuing?

Central Service TechnicianEKG (Electrocardiogram) TechnicianElectronic Health Records SpecialistEquity, Inclusion, and Diversity of the Human ExperienceGeneral X-Ray Machine OperatorHealth Unit CoordinatorPatient Care TechnicianPhlebotomy
First Name*
Last Name*
Middle Name
Previous Names
Current or previous UC Student?*

YesNo
UC ID# (if applicable)
Street Address*
Street Address Line 2
City*
State / Province*
Postal / Zip Code*
Phone Number

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Years & Months of Consecutive residence in Ohio immediately preceding today:*
Current UC or personal email *
Term for which you plan to Enroll
U.S. Citizen?*

YesNo
Ethnicity*

Hispanic/ LatinoNot Hispanic/Latino
Race (check all that apply)*

American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/ Pacific IslanderWhiteOther
High School Name, City and State*
High School Graduation date*

MonthDayYear
Date
Since 9th grade, have you been disciplined at a school you have attended for academic or behavioral misconduct (Disciplinary actions could include, but are not limited to: probation, suspension, removal, dismissal, or expulsion.)

YesNo
Have you ever been found guilty or convicted of a misdemeanor, felony, or other crime? (Note that you are not required to answer "Yes" to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded, or otherwise ordered by a court to be kept confidential.)

YesNo
I understand that I am requesting adding a micro-credential.*

I Understand
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