University of Providence

SHP Course Application

This is an application creation scoped form for registering students for the Exam Prep course.

Please complete the required fields below. You will receive a confirmation email once your application has been submitted.

Biographical Information

Email Address

First Name

Middle Name

Last Name

Birthdate

Gender

Social Security Number (omit dashes)

Phone Number

Mailing Address

Country

Street

City

Region

Postal Code

Demographic Information

The questions in this section are voluntary and information provided is for demographic research purposes only.

Hispanic | Latino

Yes

Application Information

Student Type

Academic Level

Academic Program

Entry Term

Location

Are you a Providence Health employee?

Yes

Providence Facility

If unable to locate facility above, please enter name

Employee ID

The University of Providence, mindful of its mission to be a witness to the love of Christ for all, admits students of any age, race, color, disability, national or ethnic origin, religion, sexual orientation, gender, citizenship status, status as a veteran, or any other characteristic that is protected by applicable state or federal law to all rights, privileges, program and activities generally accorded or made available to students at the University.

Your signature below certifies the following:

I understand once my application has been submitted it may NOT be altered in any way.

The information submitted in the application is my own work, factually true and honestly presented. I authorize the school attended to release all requested records and authorize review of my application. I understand I may be subject to a range of possible disciplinary actions including admission revocation or expulsion, should the information I certified be false.

Signature (please type full legal name)

Date

* Denotes required field.