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
*
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
County in the state in which you live (ex: Hamilton, Clermont)
*
Years & Months of Consecutive residence in Ohio immediately preceding today:
*
Phone Number
-
Area Code
Phone Number
E-mail
*
Birth Month
*
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
*
Birth Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
*
Birth Year
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Sex
*
Female
Male
Males 18 years or older, are you registered with the Selective Service (www.sss.gov)
Yes
No
Selective Service Number
U.S.Citizen
*
Yes
No
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/Latino
Not Hispanic/Latino
Race (check all that apply)
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Other
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?
Yes
No
College of Allied Health Non-Matriculated Program
*
Speech Language Pathology
Occupational Therapy
Physical Therapy
Athletic Training
Distance Learning
Yes
No
Have you ever applied to or attended UC?
*
Yes
No
Not 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 interest
To be a visiting student from another campus
To take only selected courses to gain skills before I start my career
To take only selected courses to upgrade skills for a current job
To take only selected courses to help me switch to a new career
To 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.
*
Yes
No
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
*
Yes
No
If yes please provide an explanation of the conviction
*
I Understand
I Understand
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