Application to the Department of Allied Health Science

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Allied Health Sciences Application

All Red fields are required.

Current Date:

Desired Date
of Entrance:

Full Legal Name

First Name:

Last Name:

Middle Name:

Maiden Name:

Student Information

SSN:

E-Mail:

Date of Birth:

Place of Birth:

Permanent Address

Street:

City, State Zip:

Home Phone:

() -

Day Phone:

() -

Mailing Address (if different than permanent address) The Same

Street:
City, State Zip:	,
Telephone #:	() -

Spouse or Guardian (if applicable): Not Applicable

First Name:		Last Name:
Middle Name:
Street:
City, State Zip:	,

Education

Highest Grade Completed:

Pre-10 10 11 12 13 14 15 16 17+

High School Last Attended:

Name:

Dates Attended:

Address:

GPA:

Colleges Attended:

Name:

Dates Attended:

Address:

Name:

Dates Attended:

Address:

Name:

Dates Attended:

Address:

Standardized Test Scores

ACT:

SAT:

Math
Verbal

What Program are you Applying for?

Allied Health Leadership

Cardiopulmonary Science

Radiography

A.A.S. to B.S. Completion Program

Cardiopulmonary Science

Radiography

This section is for Dental Hygiene Applicants ONLY

Have you taken any of these courses previously?

Anatomy & Physiology I	Final Grade: Institution:
Anatomy & Physiology I Lab	Final Grade: Institution:
Anatomy & Physiology II	Final Grade: Institution:
Anatomy & Physiology II Lab	Final Grade: Institution:
Microbiology	Final Grade: Institution:
Chemistry	Final Grade: Institution:
Other:

Do you have any Dental Hygiene Work Experience. If so, explain. Please include Location, length of experience, hours of experience, and duties. Yes No


Do you have any other Dental Hygiene Experience. If so, explain. Yes No

Do you have a physical or mental health condition which would cause you or any other person to be placed in danger if you are admitted to the program? If yes, please explain below.

Yes
No

Because the department seeks to provide, in as much as possible, a reasonable safe environment for its health careers students and their patients, a student may be required during the course of the program, to demonstrate his/her physical and/or emotional fitness to meet the essential requirements of the program. Such essential requirements may include freedom from communicable diseases, the ability to perform certain physical tasks, and suitable emotional fitness. Any appraisal measures used to determine such physical and/ or emotional physical fitness will be in compliance with Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990, so as not to discriminate against any individual on the basis of disability.

Have you ever been convicted of, or pleaded guilty to a criminal charge directly pertinent to this program? If so, please provide the requested information.

Yes
No

An affirmative response will not necessarily bar admission. Factors such as age at the time of conviction, elapsed time, seriousness and nature of the crime, and rehabilitation will be taken into account.

Students with a "yes" answer to the question are advised to consult with the board regarding his/her licensure/registration/certification eligibility.

Status of ETSU Application

Not Yet Applied Application Submitted Accepted Current Student

Information Confirmation

Yes, the preceeding information is true

Name:

Date:

Email:

An East Tennessee State University application must also be completed.