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.

* Required fields

Personal Information

* First Name: * Last Name:
Middle Initial:	Maiden/former Name:
Address:	City:
State: ZIP:	* Home Phone:
Cell Phone: May we text your cell phone: *see note below
Work Phone: May we contact you at work:
* E-mail: Driver's License #
Date of Birth:	Ethnic:
Are you a Veteran:	Citizenship:

Alt.Contact Name:
Relationship: Alt.Phone:

Have you ever been convicted of or have pleaded guilty to any crime?
If "yes", please explain:

Condition of Health: Please explain any special health requirements or any physical problems? Known allergies:

Program of Interest

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

Education Information

GED -- Year Completed: State in which GED exam was taken:
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 Name, City & State:	Year attended/ graduated:	Program of study, type of degree or diploma earned:
1.
2.
3.

Employment History
Please list job experience, starting with the most recent job first.

	Employer Name & Address	Position Held	From (date):	To (date):
1.
2.
3.

References

	Name / Relationship	Address / City,ST,Zip	Phone #
1.
2.
3.

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.

* If you opted-in to receive SMS/Text Messages on your cell phone, it will only be used to send you communication pertaining to your enrollment. Please be aware your cell phone carrier may charge a fee for delivery of messages based on you current calling plan. Your number will not be given to any third party. You may opt-out in writing at any time.

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.

* By placing my initials in this box, I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for rejection of this application or dismissal, if enrolled.

Click here to submit your application.