Healthcare Academy Application

NONDISCRIMINATORY POLICY STATEMENT: It is the policy of Bellin College to be nondiscriminatory because of color, race, national origin, religion, age, sex, marital status, or handicap in the admission of students, in student programs, and in the employment of College faculty & staff.

  • MM slash DD slash YYYY
  • Number is used for identification purposes only.
  • 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.
  • Person to be notified in case of emergency:

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

  • Signature

  • MM slash DD slash YYYY
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