Entrance Survey Fall 2023

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Joining our program next semester? Give us your information! Just a reminder, there is a $200 fee that covers the cost of your Dub Scrubs personalized embroidered scrubs, personal suturing pad, parking pass, etc. DO NOT COMPLETE THIS FORM UNTIL YOU ARE A REGISTERED CONCURRENT ENROLLMENT STUDENT! CONTACT KEELY BRINN at (801) 425-8129 for questions!

First Name *

Last Name *

Date of Birth *

YYYY

Place of Birth *

Gender *

Female

Male

Other:

Ethnicity *

Will you be the first in your family to earn a college degree? *

Yes

Weber State Email Address (must be a CE student) *

Cell Phone Number *

Format: (123) 456-7890

School *

GPA *

4.0

3.9

3.8

3.7

Other:

ACT Score *

Medical Area of Interest *

W# *

If you are a concurrent enrollment student through Weber State, this can be found under your account information on www.weber.edu. If you are not yet a concurrent enrollment student, you will need to contact the program manager, Sydney Carlson at (801) 920-5387, for information on how to become a concurrent enrollment student.

T-shirt Size *

XXL

Are you CPR certified? *

Yes

If you are CPR certified, who were you certified through? *

American Heart

Red Cross

I am not CPR Certified

Other:

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