Basic Data Form College of Allied Health

College of Allied Health Basic Data Form
First Name*
Last Name*
Middle Name
Previous Names
UC ID#
Street Address*
Street Address Line 2
City*
State / Province*
Postal / Zip Code*
Country*
County in the state in which you live (ex: Hamilton, Clermont)*
Years & Months of Consecutive residence in Ohio immediately preceding today:*
Phone Number

Area CodePhone Number
E-mail*
Birth Month*
Birth Day*
Birth Year*
Sex*

FemaleMale
Males 18 years or older, are you registered with the Selective Service (www.sss.gov)

YesNo
Selective Service Number
U.S.Citizen*

YesNo
If not a citizen of the United States, list country of birth and country of citizenship
If not a US Citizen, Type of Visa (ex. Perm. Res, A, H, L, TN, etc.)
Ethnicity

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

American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteOther
Name of High School Where You Attended:*
High School Graduation Year*
High School City and State*
Have you been accepted to a University of Cincinnati Program this year?

YesNo
College of Allied Health Non-Matriculated Program*

Speech Language PathologyOccupational TherapyPhysical TherapyAthletic Training
Distance Learning

YesNo
Have you ever applied to or attended UC?*

YesNoNot Sure
If Yes, Dates Attended UC
Degree(s) Earned at UC:
If you attended other institutions of Higher Education - List Institution's Name and Location
Dates Attended
Degree(s) Earned
Current Employer Name, City and State
Dates Employed
Academic Intentions - Please select all that apply*

To obtain knowledge for personal interestTo be a visiting student from another campusTo take only selected courses to gain skills before I start my careerTo take only selected courses to upgrade skills for a current jobTo take only selected courses to help me switch to a new careerTo take select courses in anticipation of applying for a degree or certificate program
Have you ever been found responsible for a disciplinary violationat any educational institution you have attended from the 9th grade (or theinternational equivalent) forward, whether related to academic misconduct orbehavioral misconduct that resulted in a disciplinary action, or are there anydisciplinary actions or investigations currently pending against you? Theseactions could include, but are not limited to: probation, suspension, removal,dismissal, or expulsion from the institution.*

YesNo
If yes please give the approximate date of each incident, explain the circumstances, and reflect on what you learned from the experience.*
Have you ever pled guiltyor been convicted of a criminal offense, other than a traffic violation, or arethere any criminal charges currently pending against you? Note that you are notrequired 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 bekept confidential*

YesNo
If yes please provide an explanation of the conviction*
I Understand

I Understand
Should be Empty:

College of Allied Health Basic Data Form