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Enrollment Application

  • To determine whether you can gain from our course of study, we ask that you answer the questions on this form. Please answer all questions as fully as you can. All information will be held in strict confidence and will be used to determine your aptitude for a career in allied health. Upon graduation, information on this form may assist with placement.
  • Admissions requirements/criteria are listed in the School Catalog.
  • Great Lakes does not discriminate against any person because of race, color, religion, sex, disabilities, age, national origin, or ancestry regarding admission to programs or placement activities.

*Fields Are Required

Personal Information
*First Name *Last Name
Middle Initial Maiden Name
*Address *City
*State Zipcode
*Home Phone Cell Phone
Work Phone
May we contact you at work? May we text your cell phone?
*Email Address Date of Birth
Driver's License # Driver's License State
Gender Ethnic
Veteran? Citizenship
Alt. Contact Name Relationship
Alt. Phone

Background and Health

Have you ever been convicted or pleaded guilty to a crime?
If yes, please explain:
Condition of Health: Please explain any special health requirements or any physical problems?
List known allergies.

Program of Interest

I am applying for:
When would you like to begin?

Education Information

GED - Year Completed State Where Completed
High School Diploma - Year Graduated:
High School Name City / State

Beginning immediately after high school, list all other training you have started and/or completed, including college, trade, or business schools:
School NameCity, StateProgram of Study, type of degree earned:
Years AttendedDid You Graduate
Yes?
School NameCity, StateProgram of Study, type of degree earned:
Years AttendedDid You Graduate
Yes?
School NameCity, StateProgram of Study, type of degree earned:
Years AttendedDid You Graduate
Yes?

Employment History
Please list job experience, starting with the most recent job first.
Employer Name & AddressPosition HeldFrom (date)To (date)
1.
2.
3.

References
NameAddressCity, State
Phone #RelationshipZip Code
NameAddressCity, State
Phone #RelationshipZip Code
NameAddressCity, State
Phone #RelationshipZip Code

Disclaimer
As part of the admission requirements, there is a $25 Application Fee due when you apply. The Application Fee is refundable if requested in writing within 60 days of the submitted Application for Admission if the applicant decides not to attend, or is not accepted.
Applicants must complete a High School Transcript and/or a GED Transcript release form. An exam will be given to determine the student's reading grade level; consult the Catalog for minimum program reading levels.
Class sizes are limited to a maximum number of students per program and will be closed to enrollment when that number is reached. Enrollment is granted on a first-come first-serve basis only to registered applicants who have completed all admission requirements. Applicant who have not become enrolled in a class that has been closed have the option to register for a future class.