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    Health Care Academy Application

    Bellin College Healthcare Academy

    Discover your passion while earning up to 42 college credits with Bellin College’s Healthcare Academy. 

    Please complete this application to enroll in the Healthcare Academy. Once completed, the Program Director, Chad Dall, will reach out to confirm course enrollment. If you have any questions, please contact Chad at chad.dall@bellincollege.edu.
    Name & Address Information
    Mailing Address
    Mailing Address
    Permission to Text
    Permission to Text
    Birthdate
    Birthdate
    Emergency Contact
    Demographic Information
    The following student data does not affect your admission status and is requested only to aid in the completion of federal, state, and college reports.
    Sex
    Sex
    Race
    Race
    School Information
    Graduation Date *
    Graduation Date *
    Checkmark each statement below to indicate that it is true and accurate
    Signature
    Date
    Date