UC Blue Ash Micro-Credential Form
Which Micro-Credential are you pursuing?
Central Service Technician
EKG (Electrocardiogram) Technician
Electronic Health Records Specialist
Equity, Inclusion, and Diversity of the Human Experience
General X-Ray Machine Operator
Health Unit Coordinator
Patient Care Technician
Phlebotomy
First Name
*
Last Name
*
Middle Name
Previous Names
Current or previous UC Student?
*
Yes
No
UC ID# (if applicable)
Street Address
*
Street Address Line 2
City
*
State / Province
*
Postal / Zip Code
*
Phone Number
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Years & Months of Consecutive residence in Ohio immediately preceding today:
*
Current UC or personal email
*
Term for which you plan to Enroll
Please Select
Fall 2024
Spring 2025
U.S. Citizen?
*
Yes
No
Ethnicity
*
Hispanic/ Latino
Not Hispanic/Latino
Race (check all that apply)
*
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/ Pacific Islander
White
Other
High School Name, City and State
*
High School Graduation date
*
-
Month
-
Day
Year
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.)
Yes
No
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.)
Yes
No
I understand that I am requesting adding a micro-credential.
*
I Understand
Click here to Submit Form
Should be Empty: