Mercy College of Health Sciences
Office of Admissions
921 6th Avenue
Des Moines, IA 50309-1200
Phone: (515) 643-6715 Fax: (515) 643-6702
Toll Free: (800) 637-2994 Ext. 3-6715
Email: admissions@mchs.edu
www.mchs.edu
Application for College Admission
Please complete all information.
* Required Entries
Personal Information
Date of Application:*  (mm/dd/yyyy) Social Security No.:* xxx-xx-xxxx
Gender (optional): Male Female Marital Status (optional): Single Married Divorced Widowed
Will you be 18 years or older at the time of enrollment?* Yes No
Birth Date:* (mm/dd/yyyy)
LEGAL NAME
Last Name:* First Name:* Middle Name: Suffix:
Preferred Name, if not first name (choose only one):
Former Last Name(s):* Enter "none" if not applicable  
CURRENT CONTACT INFORMATION
Number and Street:* Effective until: (mm/yyyy)
City:* State:*
Zip Code:*
Country: County (if in Iowa only):
Home Phone:* (xxx-xxx-xxxx) Email Address:*
Work Phone: (xxx-xxx-xxxx)
Fax Number, if available:
(xxx-xxx-xxxx)
Cell/Other Phone: (xxx-xxx-xxxx)
PERMANENT ADDRESS (if different than above address):
Number and Street: City: State:
Zip Code: Country:
County (if in Iowa only):
EMERGENCY CONTACT
Name:*
Emergency Contact Phone:*
(xxx-xxx-xxxx)
Relationship to Contact:*
Number and Street:* City:* State:*
Zip Code:*
LANGUAGE
Is English your native language?* Yes No
SOURCE
How did you hear about Mercy College?*
 
Demographics
CITIZENSHIP*
HOW WOULD YOU DESCRIBE YOURSELF? (optional)
Colleges and universities are asked by many, including the federal government, accrediting associations, college guides, newspapers, and our college/university communities, to describe the ethnic/racial backgrounds of our students and employees. In order to respond to these requests, we ask you to answer both of the following two questions:
Do you consider yourself to be Hispanic/Latino/Spanish Origin? Yes No
In addition, select one or more of the following racial categories to describe yourself:
American Indian or Alaskan Native Native Hawaiian or Pacific Islander
Asian White
Black or African American  
RELIGIOUS PREFERENCE (optional)
ARMED SERVICES (optional)
Are you a US Armed Services Veteran? Yes No
Are you intending to use military or veterans' educational benefits? Yes No
Academic Program Identification
Have you previously applied for admission to Mercy College?* Yes No
Have you previously attended Mercy College?* Yes No
SHORT-TERM CERTIFICATE PROGRAMS
Are you applying for admission to a short-term certificate program?* Yes No
DEGREE PROGRAMS
Are you applying for admission to a degree program?* Yes No
Do you plan to file for the current year Free Application for Federal Student Aid (FAFSA)?* Yes No
Have you taken the ACT or SAT college entrance exams?* Yes No    
 
Secondary Education
List in chronological order the high schools you attended between grades 9-12.
(Applicants applying for the following programs do NOT need to send in official copies of their high school transcripts; however, do need to complete this section: Clinical Laboratory Science Certificate, Critical Care Emergency Medical Transport (CCEMT), Emergency Medical Technician (EMT), Bachelor of Science in Health Care Administration, Nuclear Medicine Technology Certificate and Bachelor of Science in Nursing).
Name of School* City and State* Dates Attended*
(MM/YYYY) TO (MM/YYYY)		 Did you
(or will you soon)
graduate from
this school?*
to Yes No
to Yes No
to Yes No
If not a high school graduate, have you earned the General Equivalency Diploma (GED)?
Yes No
Post-Secondary Education
Name of School City and State Dates Attended
(MM/YYYY) TO (MM/YYYY)		 Did you graduate from this school? Degree Earned
to Yes No
to Yes No
to Yes No
Are you currently attending another educational institution?* Yes
No
Current Course Schedule
List all college courses in which you are currently enrolled. Please convert quarter hours to semester credit hours, if applicable.
*Quarter hours convert to semester credit hours at the value of 1 quarter hour = 2/3 semester credit hour.
Course Number Course Name Credit Hours
Planned Course Schedule
List all college courses you are planning to enroll in next semester at Mercy College (or other institution).
Please convert quarter hours to credit hours, if applicable.
*Quarter hours convert to semester credit hours at the value of 1 quarter hour = 2/3 semester credit hour.
Course Number Course Name Credit Hours
Health Care Licensures and Certificates
Have you completed any health care education that leads to licensure or a certificate?*
 Yes No
Employment and Professional Experience
List employment and professional experience. Begin with most recent position.
Dates of Employment
(MM/YYYY) or Present		 Name and Location Position Held Number of Hours
Worked per Week
to
to
to
to
Applicant's Signature

As future members of the healthcare profession, the students of Mercy College of Health Sciences bear a special responsibility to maintain high ethical standards for the profession. Accordingly, it is expected that each student will scrupulously regard the rights of others and will observe high ethical standards of both personal and professional conduct. The Mercy College of Health Sciences Academic Integrity Statement sets forth our expectations for our students.

All Mercy College students are bound by the Academic Integrity Statement and Student Handbook. I agree to be bound by the Academic Integrity Statement and Student Handbook as they are adopted. The Academic Integrity Statement and Student Handbook are, however, not the exclusive sources of professional standards and student disciplinary rules and procedures. Mercy College reserves the right to establish, modify and enforce academic and professional standards governing satisfactory performance of students and their conducts while enrolled at Mercy College.

I certify that the information contained herein and in any supplemental documents submitted to Mercy College is true, correct and complete to the best of my knowledge. I shall promptly notify Mercy College school officials in the event that anything happens prior to my enrollment at Mercy College that would change the information contained in this application or its supporting documents. I understand that the obligation to report changes extends to the period of time during my enrollment as well. I understand that any false or misleading statement, omission of subsequent or material facts, or incomplete application may be the basis of denial of admission, revocation of an offer of admission, or dismissal from Mercy College of Health Sciences, if already enrolled.

Please be advised that admission to and graduation from Mercy College of Health Sciences does not guarantee employment in the healthcare profession. Mercy College of Health Sciences makes no representation regarding a student's eligibility to be licensed in any healthcare profession or ability to be employed in the healthcare profession.
Signature:* Date:* (mm/dd/yyyy)
It is Mercy College's policy to conduct all academic programs and business activities in a manner that is free from discrimination and to provide equal opportunity for and equal treatment of students regardless of race, color, national and ethnic origin, age, sexual orientation, gender identity, religion, creed, physical or mental disability, status as a disabled veteran or veteran of war, or any other factor protected by law.


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