Healthcare Academy Application

Date*

Name*

Last First Middle

Previous Name(s)

Mailing Address*

Number and Street City State ZIP / Postal Code Country

County*

Email*

Phone Number*

Date of Birth*

Social Security Number*

Number is used for identification purposes only.

High School*

Grade Level*

Freshman
Sophomore
Junior
Senior

Sex and Ethnicity

The following student data does not affect your admission status and is requested only to aid in the completion of federal, state, and college reports.

Sex*

Male
Female

Ethnicity*

Person to be notified in case of emergency:

Name:*

First Last

Email

Relationship

Phone*

Select each statement below to indicate that it is true and accurate

Select (check) each box:*

The information I have provided is correct in all aspects.
I understand that this registration does not imply current or future admission to any Bellin College degree program option. If I wish to apply for admission into one of the programs of study, I must complete a Bellin College Undergraduate application.
I understand that the courses taken will be granted college credit at Bellin College and may transfer to another institution only at its discretion, according to its transfer rules.
I understand that completion of this credit will result in the creation of a permanent enrollment record at Bellin College.
I confirm that college policy regarding the Family Educational Rights and Privacy Act (FERPA) and access to my student record was explained to me.
I agree that I am liable for all fees related to this enrollment. I agree to all conditions outlined in the Bellin College Tuition & Fee Schedule.
I understand that enrollment requires payment in full by the first day of class. Payment is refundable if I withdraw prior to first class meeting.

Signature

Sign by printing your name in the box below.*

Date*

BC Family

Visitors

BC Family

Visitors

Healthcare Academy Application

Sex and Ethnicity

Person to be notified in case of emergency:

Select each statement below to indicate that it is true and accurate

Signature

BC Family

Visitors

Healthcare Academy Application

Sex and Ethnicity

Person to be notified in case of emergency:

Select each statement below to indicate that it is true and accurate

Signature

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