Dual Enrollment - Health Sciences Charter School

What is the name of your High School? (If it is not listed, please stop & email [email protected] for the link to the correct application).*

Health Sciences Charter School

Have ever applied to Trocaire College?*

Yes
No

Student Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Country of Birth*

Date of Birth

Student Social Security Number*

Student Email Address*

Information below is needed for Federal Government Regulations. What is your ethnicity?*

Hispanic or Latino
Not Hispanic or Latino

What is your race?*

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Parent or guardian name*

Parent or Guardian Phone Number*

Parent or Guardian Email Address*

Emergency Contact (Name, relationship, phone #)*

I am requesting to take the following course(s) at Trocaire College below*

Enrollment semester*

Fall 2024

Student Consent*

I accept

Trocaire College is committed to ensuring a healthy and safe campus community. The College reserves the authority and discretion to impose health and safety restrictions and regulations deemed appropriate (may include but not limited to vaccination, booster, and/or other health care related action) at any time, due to changes in local conditions and/or requirements imposed by Federal, State, or local authorities for its campus.

Certain employees, students, and volunteers at healthcare facilities, hospitals, or any external affiliate location may be subject to mandatory immunization and/or other healthcare related requirements pursuant to dictate their own requirements. Trocaire does not set or enforce those requirements. A student who is unwilling or unable to comply with such requirements may be excluded from certain course requirements (including clinical) that could impact matriculation.

Attestation: I have read, understand, and pledge compliance with the aforementioned declaration. Further, I understand that once this attestation is endorsed, via my signature, that I hold Trocaire College free of harm and liability resulting from activation of said declaration.

Student Consent*

I accept

I hereby certify that by selecting the “I Accept” button, I am signing this request form electronically and that my electronic signature is the same as my handwritten signature.

Parent Consent*

I accept

I hereby certify that by selecting the “I Accept” button, I am signing this request form electronically and that my electronic signature is the same as my handwritten signature.

Date

Dual Enrollment – Health Sciences Charter School

Welcome to Trocaire College!

Dual Enrollment - Health Sciences Charter School