Health Sciences - Nursing Admission Application

Health Sciences

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Is Health Care for Me?

Courses Offered

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Selected Admission Forms

Basic Nurse Assistant Training Program

Coding Specialist

Emergency Medical Services

Health Information Technology

Massage Therapy

Medical Continuing Education

Medical Assistant

Medical Transcription

Nursing

Phlebotomy

Polysomnography Technology

Radiologic Technology

Respiratory Therapy

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General Information

The fields indicated by an asterisk are required.

First Name		*
Last Name		*
Middle Name
Maiden Name
SSN		*
Address		*
City		*
State		*
Zip Code		*
E-mail Address
Home Phone		*
Date of Birth		*
U.S. Citizen		*
If no, type of Visa
High School Attended		*
High School/GED Completion Date		*
Admission
Colleges Attended

Ethnic Origin

Please choose your ethnic origin for statistical purposes only.

Native American Indian
African American - Black
Hispanic or Latino
Caucasian - White
Nonresident alien
Refuse to indicate

Program Information

I am applying for

Coding Specialist Program
Health Information Technology Program
Medical Transcription Program
Nursing Program
Phlebotomy
Polysomnography
Radiology
Respiratory Therapy Program

If you are applying for the Nursing Program

I am an L.P.N. with current licensure in the State of Illinois seeking the R.N. completion track for L.P.N.s

Yes
No

I am a transfer student previously enrolled in a Nursing program seeking advanced placement in MVCC's Nursing Program. (If you marked this box, you should complete this online form and contact a Nursing representative in the Career Programs office in B150 or call (708)974-5708)

Yes
No

Program Options

Choose one of the following options

	Use only Moraine Valley credit hours toward grade point average calculation, degree requirements, and prerequisites.
	Use all college hours toward grade point average calculation, degree requirements, requirements, and prerequisites.