Health Science Enrollment Form

Health Science Enrollment Form

Student Information

Student Name:

Parent / Guardian (if student is a minor)

Minor (under 18): I affirm the student is under 18.

Program Enrollment

Tuition, Fees, and Payment

Annual Tuition: $    Enrollment Fee: $

Full payment due at registration
Installment plan (institutional payment plan; additional fees may apply)
Applying for institutional scholarship or aid

By enrolling, the student accepts financial responsibility for all tuition and fees assessed. The institution's refund and withdrawal policy applies to tuition adjustments; failure to attend does not negate financial obligations unless withdrawal is processed in accordance with institutional procedures.

Prerequisites, Certifications, and Health Requirements

Applicants must meet program prerequisites and maintain required certifications and immunizations as a condition of continued enrollment. Indicate current documentation provided:

Current CPR/First Aid certification (if required)
Background check completed
Drug screen completed
Immunizations on file / documentation attached

Health and Emergency Information

Clinical Placement, Background Checks, and Consent

I understand that participation in clinical placements and externships is a required component of the Health Science program. Clinical sites may require background checks, drug screening, immunization verification, and additional site-specific onboarding. Continued enrollment and eligibility for clinical activities are conditioned upon satisfactory completion of all required screenings and documentation.

By signing this form, I authorize the institution to obtain and share relevant academic and health documentation with clinical partners for the purposes of placement and compliance, and I consent to any required background checks or health screenings. I acknowledge that certain clinical sites may refuse placement for reasons beyond the institution's control, and that the institution's obligation is to make reasonable efforts to secure placements consistent with program requirements.

Academic Policies & Code of Conduct Acknowledgment

I acknowledge that I have reviewed and agree to abide by the program's academic policies, attendance requirements, professional standards, and code of conduct. I understand that violations of professional standards, academic dishonesty, or failure to meet health and background requirements may result in denial of clinical placement, removal from courses, or dismissal from the program.

Acknowledgment: I have read and agree to comply with academic and professional standards.

Certification and Applicant Statement

I certify that all information provided on this enrollment form and supporting documentation is true, complete, and correct to the best of my knowledge. I understand that falsification of information or omission of material facts is grounds for denial of admission or subsequent disciplinary action. I authorize the institution to verify any information provided and to request additional documentation as necessary to determine eligibility for admission and clinical placement.

I acknowledge that acceptance into the Health Science program may be conditional upon submission of required health documentation, satisfactory background screening, and payment of applicable fees.

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