Health Career Session Participation Form

This form is not an application to a health career program. This participation form must be completed, signed, and submitted upon finishing today’s Health Career Session. Your participation fulfills one of the program admissions requirements necessary to qualify for the health career program which you applied to.

Name *

First

Last

QCC ID

I am a *

New Student

Current Student

Applied Student

Guest

Date of Birth *

Month

Day

Year

Phone *

Email *

Address

Country

Address 1 *

Address 2

City *

State *

ZIP code *

Agreement

Please initial each statement

By signing this form, I acknowledge that I have read and understand the entire Health Careers Session information. By so doing, I understand that I have met the “Attend Health Career Session” program admissions requirement. *

I agree that I am responsible for all information within. Specifically, I understand that some programs may have additional admissions requirements and/or have a waitlist. *

It is my responsibility to meet all of the program admissions requirements for the health career of my choice. I understand the program requirements and the process are subject to change. *

Signature *

Please type your full name.

Leave this field blank

swhitters [at] qcc.mass.edu (subject: Webform%3A%20Help) (Need help?)

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