Delaware Institute of Health Sciences, Prospective Student Form


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	DIHS Campus
	4708 Kirkwood Highway, 2nd Flr.
	Wilmington, DE 19808
	(302) 633-4010

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Academic Calendar Class of 2009.doc
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PROSPECTIVE STUDENTS

We offer prospective students the opportunity to receive our course catalog by mail. This form also serves as a first step towards the admission process.

Please provide the following information and we will mail your packet. Keep in mind that we, at
Delaware of Health Sciences, take the privacy and security of your personal information seriously.
Feel free to review our Privacy Policy.

Name:

Maiden Name (if different):

Date of Birth:

Street Address:

City, State, Zip:

Email Address (REQUIRED) :

Daytime Telephone:

Do you wish to have us call you?

Yes:

No:

Sex:

Male:

Female:

Employer:

Phone:

Employer Street Address:

Employer City, State, Zip:

EDUCATION

I graduated from high school:

Yes, Year Graduated:

No:

I have a GED:

Yes, Year GED:

School Name/Test Center:

School/Test Center City, State:

College (If applicable):

Certified Nursing Assistant or
Home Health Aid:

Yes:

No:

Prior Health Care Experience:
(Describe)

Comments:

Delaware Institute of Health Sciences shall provide employment assistance to graduates who have met all graduation and financial requirements. There is no promise or guarantee of placement.

Education with emphasis on learning, community, responsibility, integrity, value, and quality nursing practice.


To view &/or print .PDF applications, you will need Adobe Acrobat Reader. To download your FREE Reader, click »

Click the Link Below to Download Full Enrollment Application: Please print, complete and return to the Admissions Office either by mail or in person.

Adm_App.doc