Application for Admission
* Full Name ( Last , First , Middle Initial
Maiden Name (if applicable):
* Address:
Address Line 2:
* City:
* State:
Work Telephone Number:
* Home Telephone Number:
Cell Number:
Age:
Gender (Check one):
* Email:
Fax (if applicable)
* Program of interest (select one):
Please select one
Electroneurodiagnostic Technology
Polysomnographic Technology
Continuing Education
* I wish to enroll (select one):
Please select one
Fall Semester
Spring Semester
Continuing Education
Educational Experience
High School/GED
* Name of School:
* Location (City, State):
* Years Completed:
Diploma/Degree:
College #1
Name of School:
Location (City, State):
Years Completed:
Diploma/Degree:
Select One
AA
BA
BS
Certificate
DR
Ed.D.
MA
MBA
MDIV
MS
M.Ed.
Ph.D.
College #2
Name of School:
Location (City, State):
Years Completed:
Diploma/Degree:
Select One
AA
BA
BS
Certificate
DR
Ed.D.
MA
MBA
MDIV
MS
M.Ed.
Ph.D.
College #3
Name of School:
Location (City, State):
Years Completed:
Diploma/Degree:
Select One
AA
BA
BS
Certificate
DR
Ed.D.
MA
MBA
MDIV
MS
M.Ed.
Ph.D.
Other
Name of School:
Location (City, State):
Years Completed:
Diploma/Degree:
Select One
AA
BA
BS
Certificate
DR
Ed.D.
MA
MBA
MDIV
MS
M.Ed.
Ph.D.
Employment History
Employer 1
Location (City, State):
Dates Employed (month/year):
Position Held:
Employer 2
Location (City, State):
Dates Employed (month/year):
Position Held:
Employer 3
Location (City, State):
Dates Employed (month/year):
Position Held:
Questionnaire
Please answer the following questions and check the appropriate box.
Are you currently working in healthcare?
If so, which department?
Years of experience:
Type:
Do you have a clinical site where you can perform the
clinical practicum portion of the program? If not, IOHS will need to arrange a contract with a local hospital or lab for your clinical practicum internship.
(This is a requirement for acceptance into the on-line course):
If yes, name of clinical site:
Supervisor's name:
Supervisor's credentials :
Supervisor's Contact Info / Phone:
Supervisor's Fax (if applicable):
Supervisor's email:
What types of procedures are performed in
this department? (Check all that apply):
Other procedures (if checked above):
In order to determine if you are ready to take an on-line course we ask that you answer the following questions.
1. Do you have an interest in on-line learning and the need for the convenience of distance learning?
2. Do you have basic computer literacy skills? (e.g., you should be comfortable sending and receiving e-mails, sending and opening e-mail attachments, downloading files, and posting your comments through e-mail or live chat.)
3. Do you have a commitment to keep up with the course schedule and assignment due dates during the semester?
4. Are you an independent learner and self-motivated?
To further determine if on-line learning is for you, click here for WebStudy® orientation. This will give you a general overview of WebStudy® and how it works. Good Luck and please feel free to contact the Institute of Health Sciences with any questions.
Applicant's Statement
I hereby apply for admission to the Institute of Health Sciences. I agree to abide by school policies. I certify that the information contained in this application is true and complete to the best of my knowledge and fully realize that omission or falsification of information will be sufficient reason for rejection of this application or for dismissal. I understand I will need to physically sign this document before it is considered complete.
