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Clinical Medical Assistant
Dental Assisting
Medical Billing & Coding
Medication Aide
Pharmacy Technician
Phlebotomy Technician
Personal Enrichment
Upcoming Classes
Bladesmithing
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Online Health Care
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Health Sciences Application
Health Sciences Application
Step
1
of
3
33%
Giving false information on the application renders the applicant ineligible for acceptance into the program.
Applying for
*
ADN Basic
VN to ADN Transition
VN
EMT
Paramedic
Pharmacy Tech
Demographics
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Maiden and/or Last
Mailing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
County
*
Phone
*
Cell
*
Personal Email
*
TC Email
Date of Birth
*
MM slash DD slash YYYY
Age
*
Sex
*
Male
Female
Race / Ethnicity
*
American Indian
Alaska Native
Asian
Black or African American
Hispanic / Latino
Native Hawaiian
Other Pacific Islander
White
This field is hidden when viewing the form
SSN
Educational History
Last enrolled at TC (month/year)
*
Major
*
Degree / Certificate
*
List all other colleges attended
*
College
Dates
Do you wish to transfer nursing, paramedic, or pharmacy technician courses from another institution?
*
Yes
No
Last nursing, EMT/Paramedic, or Pharmacy Tech course in which you were enrolled
*
Course
Grade
Survey
What source led you to the TC program?
*
Radio
TV
Friend/Family
TC Faculty
Newspaper
Social Media
Other
Other, please explain
*
Name of the TC Faculty member
*
What makes you a good candidate for this program?
*
Why did you choose this health program?
*
Past or current leadership roles (church, social, professional, etc.)
*
Health Services Background
Are you:
*
LVN/LPN?
EMT?
CNA?
Where did you complete the program?
For LVN/LPNs,
*
are you interested in the LVN-ADN Transition Program?
Certificate/License expires
Financial Aid
Are you planning to seek financial aid?
*
Yes
No
What type?
*
Obstacle Avoidance
Do you foresee any problems regarding enrollment; i.e., financial, transportation, child care, etc?
*
Yes
No
What problems?
*
For guidance purposes only, have you ever been arrested for anything other than a minor traffic violation?
*
Notice to all applicants: The state licensure/certification agencies may refuse to admit persons to the licensure examination who have been convicted of a felony or a crime of moral turpitude; fraud; mental/physical impairment and/or chemical dependency; etc., that could result in injury to others. For guidance regarding these limits discuss the procedure with the Enrollment Specialist or faculty before completing the application process.
Yes
No
What is your present physical condition?
*
Good
Fair
Poor
Present Height
*
Present Weight
*
Describe any past or present major illness, chemical dependency or physical limitations
*
If none, please type ‘none’.
Have you ever been denied admission or re-entry to a health program?
*
Yes
No
Please explain
*
Consent Agreements
I give my consent to the college to request references from the employing agency, previous nursing or health professional school and/or information from my physician or any other health provider, if necessary.
*
Yes
No
For what cause?
*
Signature for consent
*
Type full name
Giving false information on the application renders the applicant ineligible for acceptance into the program.
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