Fort Hays Tech | North Central ADN Application | Fort Hays Tech North Central

I am applying to the ADN Program on the following campus:

Beloit Campus

Hays campus

Both Campuses

First

Last

Maiden Name (if applicable)

Date of Birth

Current Address

City/Town

State

ZIP/Postal Code

Permanent Address (if different than current address)

City/Town

State

ZIP/Postal Code

Email Address

Cell Phone

What is your primary language?

Optional Information

Ethnicity

White

Black/African American

Asian

American Indian/Alaska Native

Native Hawaiian/Pacific Islander

Multiracial

Other…

Gender

Female

Male

Choose not to indicate

Self-Reported Pre-Requisite Information

You will need to send your official transcript(s) to Fort Hays Tech | North Central to make your application process complete. Information provided in this section does NOT take the place of official transcripts.

Please indicate if the course is complete (with a C or better), in progress, if you have not yet taken the course, or if you are unsure if the course you took at another institution is transferrable as the same course.

Human Anatomy & Physiology with Lab (5 credit hrs)

General Psychology

Human Growth & Development

Principles of Nutrition

Intermediate OR College Algebra

English Composition I

Microbiology with Lab

Are you IV Therapy Certified

Month/Year of initial LPN/LVN Licensure (if you don't know exact date, please use the first of the month)

State of current LPN/LVN licensure

Education

High School Name

High School Graduation Year:

Name of Previous College Attended (if applicable) - #1

Name of Previous College Attended (if applicable) - #2

Name of Previous College Attended (if applicable) - #3

I certify that to the best of my knowledge all statements that I have made on this application are complete and accurate. Additionally, I have completed the items on this application in their entirety and will provide Fort Hays Tech | North Central the documents required as a condition of admission and enrollment.

Name

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Fort Hays Tech | North Central ADN Application

Optional Information

Self-Reported Pre-Requisite Information

Education

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