Jotform Request Form - Firelands Respiratory Care

Firelands Respiratory Care
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Personal Email*
example@example.com
What is your preference for method of contact? Mark all that apply:*

TextCallEmailAny method is fine
Which degree are you interested in completing? (may select more than one)*

Associate of Applied Science in Respiratory CareBachelor of Science in Respiratory Care
Are you a Registered Respiratory Therapist looking to advance your education?*

YesNo
For which program location are you applying?

Base program at BGSU FirelandsSatellite program at Lorain County Community College (LCCC)
Are you a current BGSU student?

YesNo
If yes, what is your BGSU email?
example@example.com
Have you ever attended another college/university? Please list college/university (if applicable):
Have you received a degree from BGSU or another college/university? Please list college/ university, degree, and major (if applicable):
I certify this information is correct, accurate, and true to the best of my knowledge. I understand that any misrepresentation of facts could be cause for refusal of admission or dismissal from the respiratory care program.

I am aware that I will need to submit a criminal background check as a condition of my acceptance into the respiratory care program. I am also aware that I will need to complete all health requirements for admission into the clinical portion of the program. These requirements can be found in the Program and Clinical Handbook posted online or upon request.
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