Program of Interest:*
How did you hear about us?*

Personal Information:

First Name*
Last Name*
Phone Number*
Secondary Phone:
Birth Date:
Have you previously applied and been denied admission to East Valley Medical College?*
If yes, please provide dates and the name under which you previously applied:
Have you previously been enrolled at East Valley Medical College?*
If yes, please provide dates and the name under which you previously applied:
Did you graduate from an East Valley Medical College Program?*
If Graduated, which Program?
Are you a U. S. Citizen?*
If not - Country of Citizenship:
Are you bilingual?*

The following information is a request on a voluntary basis. Failure to respond will not affect the admission decision.

Funding Options
Ethnic Origin:
Current Occupation:
Current Employer:

Non-Discriminatory Policy

East Valley Medical College does not discriminate against students or potential students on the basis of race, creed, color, national origin, sex, sexual orientation, marital status, religion, age, disability, citizenship or veteran or military status, or the presence of any sensory, mental, or physical disability or the use of a trained guide dog or service animal by a person with a disability. The school does not discriminate against a student with a disability who requests a reasonable accomodation in any of its activities, programs, admission policies, academics, advertising, placement or any other services, activites or functions of the college. East Valley Medical College endeavors at all times to be in full compliance with Title IX and the Educational Amendment Act of 1972. Discrimination in any form will not be tolerated by East Valley Medical College, whether by students, staff or faculty and is cause for dismissal. Any person unlawfully discriminated against, as described in ORS 345.240, may le a complaint under ORS 659A.820 with the Commissioner of the Bureau of Labor and Industries

Academic Information:

Do you have a physical or learning disability?
If yes, do you have an Educational IEP?
If yes, describe and list accommodations needed:

Academic History:

High School Name
High School Grad Date
High School State
High School City
College Name
College -Years Attended
College - City
College - State

Emergency Contact:

Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship

Disciplinary History:

Do you have a Level One Fingerprint Clearance Card?
Have you ever been convicted of a crime?
Have you ever been expelled, suspended, dismissed,placed on probation from a place of Education?
Do you have the ability to pass a drug test?
Clicking the 'submit' button constitutes your express written consent to be contacted by East Valley Medical College at the information provided, regarding furthering your education.