Change of Program Request Form

 Please complete the form below.

Name*
Student ID*
Date of Birth
 / 
 / 
E-mail:*
E-mail confirmation:*
Phone:
-
Do you receive Financial Aid?*
If you receive TOPS, be aware that changing your program can affect your TOPS eligibility.
Would you like to be contacted by an advisor before a program change is made?*
Current Program*
Reason for change:
Desired Program:*

^ Student must apply to & be accepted into the clinical area. Student must have obtained a high school diploma or GED to apply to clinicals.

^^ Student must apply to & be accepted into each clinical area—Nurse Assistant, Phlebotomy, and EKG—to complete the Patient Care Technology program.

By signing and submitting this form, you acknowledge that your electronic signature is the is the legally binding equivalent to your handwritten signature. Additionally, by signing and submitting this form, you hereby request a change of program.

Signature:*
Date:*