Certificate of Medical Humanities - Hospital Application Form

First Name*

Middle Name

Last Name*

Email Address*

Primary Phone Number*

Mobile Phone Number

Mailing Address*

Country

Street

City

Region

Postal Code

Academic Plans

Program*

Entry Term*

Hospital Association*

Personal Information

Birthdate*

Sex*

Citizenship*

Are you a Permanent Resident of the United States?

Yes

Birth Country*

Optional Race/Ethnicity Information

Are you Hispanic or Latino?

Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific

White

Disciplinary / Criminal History

Have you ever been placed on academic or disciplinary probation or resigned or been suspended, expelled, or requested/advised to resign from any college, university, professional school or school of theology? Disciplinary action includes any probation, suspension, removal, dismissal, or expulsion as a result of any academic or behavioral misconduct. *

Yes

Please Explain:

Have you ever been convicted of a felony in any state or country?*

Yes

Please Explain:

Application Certification

I understand that once my application has been submitted it may NOT be altered in any way.*

Yes

I certify that all of the information submitted in the application is my own work, factually true, and honestly presented. I authorize all schools attended to release all requested records and authorize review of my application. I understand that I may be subject to a range of possible disciplinary actions, including admission revocation or expulsion, should the information I certified be false.*

Yes

I understand that an offer of admission is conditional, pending receipt of final transcripts showing work comparable in quality to that upon which the offer was based.*

Yes

Electronic Signature

The electronic signature consists simply of your name, typed by you on your keyboard. The signature is your confirmation that the application you have filled out is your own work and the information is factually true. Once you type in your name, this will count as your electronic signature.*

Drew

Certificate of Medical Humanities - Hospital Application Form

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