Online Survey | KSU Medical Assisting Certificate Program

Kent State University Student Flashline I.D.

Last Name:

First Name:

Middle Name:

Maiden/Former Name:

Street number & name, or P.O. Box:

City:

State:

Zip Code:

Primary Phone Number:

Alternative Phone Number:

Kent State University Email Address: (all official communication will come to this address).

Alternative Email Address:

Which campus would you prefer?

Ashtabula
Geauga Burton

Are you currently a high school student?

Yes
No

Are you a College Credit Plus (CCP) student? If yes, list the college (s) that you have attended:

Yes
No

Are you currently enrolled at another college or university? If yes, please indicate where.

Yes
No

The following criteria will be considered in the approval of your application. If you select "NO" to any of the following, you will be contacted by an Academic Advisor for the next steps in the admission process.

The following criteria will be considered in the approval of your application. If you select "NO" to any of the following, you will be contacted by an Academic Advisor for the next steps in the admission process.
	Yes	No
You have graduated from an accredited high school or demonstrated equivalency through the GED exam.	Yes	No
You have been admitted to Kent State University.	Yes	No
You have successfully completed college level medical terminology, and human biology or higher anatomy and physiology course with a lab. (Must be completed prior to beginning the fall Medical Assisting coursework).	Yes	No
You have earned a cumulative GPA of 2.0. (a GPA will not be rounded).	Yes	No
You have earned a grade of "C" (2.00) or higher in all specified required courses prior to admission in the Medical Assisting Program.	Yes	No
You have submitted official transcripts to Kent State University, as applicable.	Yes	No

Please click "Yes" to indicate you have read and understand each delegation listed below. Thank you.

Please click "Yes" to indicate you have read and understand each delegation listed below. Thank you.
	Yes
I attest that all information in this application is complete and accurate.	Yes
I understand that any omissions or falsifications of these documents may result in denial of admission or immediate dismissal for the MA Program.	Yes
I understand that a past conviction on my background check may prevent my clinical placement and the inability to complete the program requirements.	Yes
I agree to complete the health clearance requirements, including a federal and civilian background check and drug screening.	Yes
I agree that it is my responsibility to confirm that all application materials are received on or before the application deadline.	Yes
I have read and understand the above information contain in the application.	Yes

By typing my full name below, I am signing my electronic signature for this application.

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