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Hispanic Nursing Project Inquiry Form

 

Inquiry Information
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
ZIP:
E-Mail:
Home Phone:
Cell Phone:
Date of Birth:
Sex: Male     Female
Are you a U.S. citizen? Yes      No
Are you Hispanic? Yes      No
Are you bi-lingual? Yes      No
Are you interested in working with the Hispanic population after graduation? Yes      No
Are you willing to minor in the Hispanic Health and Human Services Minor? Yes      No
Education Information
High School:
GPA:
Class Rank:
Graduation Year:
ACT Composite Score:


English
Math
Reading
Sci Reason

Math classes, grades and year:
Science classes, grades and year:
Have you taken Spanish in High School? Yes      No
How many years?
Does your school have a
Health Careers program?

Yes      No

Did you participate in it? Yes No
Colleges Attended (if any):
What, if any, education do either of your parents have beyond high school?
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