First Name: *

Last Name: *

Select your Program *
- Select Option GVSU Entry Level Track GVSU & MCC 1+2+1 Track

Student G-number (if applicable):

Provide your GVSU Email Address (if applicable)
Please enter a GVSU student email address ending in @mail.gvsu.edu.

Provide your personal email address *

Cell phone or best number to reach you: *

Date of Birth: *
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Local Street Address: *

Local City: *

Local State: *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming

Local Zip Code: *

Permanent Street Address: *

Permanent City: *

Permanent State: *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming

Permanent Zip Code: *

Emergency Contact (name): *

Emergency Contact Relationship: *

Emergency Contact Street Address: *

Emergency Contact City: *

Emergency Contact State: *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming

Emergency Contact Zip Code: *

Emergency Contact Phone: *

Current GPA: *

Please list all previous colleges and universities attended. Include ALL schools AND cumulative GPA from each school:

Are you currently taking classes at GVSU? *
- Select Option Yes No

Are you officially admitted to GVSU? *
- Select Option Yes No

If you are not currently enrolled at GVSU or are enrolled but have not yet taken GVSU classes and have not met with a College of Health Profession (CHP) academic advisor, you should:

1. Meet with a CHP academic advisor as soon as possible to review your transfer course equivalencies and program eligibility.
2. Call the CHP Student Services Office at (616) 331-5900 to set up a prospective student advising appointment.

Will you or have you completed a bachelor's degree prior to the start of the program? *
- Select Option Yes No

Please list the college/university name, major and expected degree date: *

Have you previously applied to the Respiratory Care program? *
- Select Option Yes No

If Yes, what application cycle? (PLEASE NOTE: All supplemental documents will NEED to be resubmitted.) *

The following criteria must be met for your application to be complete:
Officially admitted to GVSU for fall start of the program
All non-GVSU transcripts sent to GVSU (if taking courses elsewhere send transcripts at end of each semester)
Minimum cumulative GPA of 2.5
Grade of "C" (2.00) higher for each prerequisite courses
Verification of Course Completion
Submission of this secondary application

Legal Charges and/or Convictions
Individuals who have been involved in a criminal proceeding or charged with or convicted of a crime may not be eligible for clinical placement and/or national certification and/or licensure. Students who are unable to complete a clinical placement may not be able to meet program requirements for graduation. If you have been charged or been convicted of a crime please feel free to submit this application, however we encourage you to contact the Respiratory Care (RSC) Program Director, Professor Ann Flint by email at [email protected] to inquire how this could impact your completion of the RSC program.

I have reviewed the requirements for admission into the respective program(s) and understand that the completion of this application does not guarantee that I will be accepted into the program.

Furthermore, if I am not currently enrolled at GVSU or am enrolled but have not yet taken GVSU classes and have not met with a College of Health Profession (CHP) academic advisor, I should:

1. Meet with a CHP academic advisor as soon as possible to review my transfer course equivalencies and program eligibility.
2. Call the CHP Student Services Office at (616) 331-5900 to set up a prospective student advising appointment.

Date: *
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