Student Qualification Form

Student Qualification Form

Program Selection

Program Applying For:   Campus/Location:

Desired Start Date:

Student Information

Parent / Guardian Information (if student is minor)

Academic Qualifications

Official transcript enclosed:   If no, expected transcript date:

Prerequisite Checklist

The applicant represents that the following prerequisites are satisfied. Check all that apply and provide documentation when requested.

Completion of required mathematics coursework

Completion of required science coursework

Completion of required English/language arts coursework

Required laboratory or practicum hours completed

Standardized Tests & Additional Evidence

Accommodations, Health, and Safety

Does the student have an IEP, 504 plan, or documented disability that may require academic accommodations? Yes No

Declaration, Consent, and Certification

By signing below, the applicant or parent/guardian certifies that all information provided on this form and in any accompanying documentation is true, complete, and submitted in good faith. The applicant understands that falsification, omission, or misrepresentation of information may result in denial of qualification, rescission of admission, or other institutional action.

The undersigned authorizes release of academic, attendance, and disciplinary records from previously attended schools and institutions for the purpose of evaluating eligibility for the selected program. The undersigned further consents to the institution’s verification of grades, credits, standardized test scores, and other credentials necessary to determine qualification.

The institution will use the information supplied to evaluate eligibility and to administer enrollment. Information will be maintained and used consistent with institutional policies. The undersigned understands that submission of this form does not guarantee admission or placement.

I agree to the statements above:

Administrative Use Only

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