Great Lakes Institute of Technology Home Page
 

Programs Offered
Dental Assistant
Diagnostic Medical Sonographer
Massage Therapist
Medical Assistant
Medical Billing & Coding
Medical Office Assistant
Patient Care Technician
Pharmacy Technician
Phlebotomy Technician
Surgical Technologist
Veterinary Assistant

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:
Address:
May we text your cell phone: *see note below
Date of Birth: Ethnic:
Are you a Veteran:
 
Alt.Contact Name:
Relationship:
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


Education Information

-
  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.

 

Keep in touch with Great Lakes on Twitter.com/Watch videos about our school and medical careers.
If you would like to find out more about programs of study offered by Great Lakes -- CLICK HERE -- and someone will get back to you right away to answer your questions.The best way to find out what Great Lakes has to offer is to visit the school and see for yourself.  CLICK HERE to let us know when you are coming!If you've seen what you like -- CLICK HERE -- and apply on-line and we'll get the ball rolling.If you need to know how to contact us -- CLICK HERE -- and we'll tell you how!

Prospective Students | What's New | Alumni | Employers| Home
Dental Assistant | Diagnostic Medical Sonographer | Medical Assistant | NEW! Medical Billing & Coding | Medical Office Assistant
Massage Therapy | NEW! Patient Care Technician | Pharmacy Technician | NEW! Phlebotomy Technician | Surgical Technologist
Veterinary Assistant
| Legal/Disclaimers | Site Map | Get Back to Me

 
a