Health Sciences Application Health Sciences Program Application Check the selection for which you are applying Fall Spring Summer Applicant InformationName First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneAlt. PhoneEmail Date of Birth MM slash DD slash YYYY Gender Last four digits of your SSN or ASU Mid-South student ID #Program Pursuing (Check One) Emergency Medical Technician (EMT) Advanced Emergency Medical Technician (AEMT) Certified Nursing Assistant Phlebotomy Paramedic Science Educational InformationHigh School Current High School Senior High School Graduate/Year GED/Year YearYearName of High School Address Street Address City Post Secondary Current ASU Mid-South Student Prior ASU Mid-South Student Current Student At Another College Prior Student At Another College Name Program Name Years Attended Important Information I have read the important informationAlthough a student may qualify for admission to a health care career program, they may not meet requisite clearance of potential employers and the licensure or certification requirements of the discipline. Verification: I attest that the information on this application is correct to the best of my knowledge. I understand that any falsification or misrepresentation of any information will be sufficient grounds for my dismissal or termination from the program.SignatureDate MM slash DD slash YYYY