DEADLINE:
First Friday in August
(Fall Semester)
Third Friday in November
(Spring Semester)
Which program are you applying for
Please Select
Nursing Assistant (NA)
Medical Assistant Certificate (MA)
Pharmacy Technician
Emergency Medical Technician (EMT)
Program Option:
Please Select
7-week hybrid NA
One semester in-person
Concurrent Enrollment
Program Option for Pharmacy Tech
Please Select
Certificate
Pathway
Which campus are you applying for
Please Select
Moab Campus
Blanding Campus
Price Campus
Which campus are you applying for
Please Select
Moab Campus
Price Campus
Name
First Name
Middle Name
Last Name
Name Previously Use
Student USU A#
Daytime Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Evening Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cellphone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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.
Format: (000) 000-0000.
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 understand that I am subject to a background check and drug screen for clinical time
Yes
I understand that I am required to have all vaccines current and submit vaccination records
Yes
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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