Personal Information

Date of Application*:   

Program of Interest*:   Select One Basic Kinesiology Program Professional Kinesiology Program Advanced Diploma Distance Commuter Program Entering With Advanced Standing Conversion Program

How where you referred to us?*   

First Name*:  

Last Name*:  

Street Address 1*:   

Street Address 2:   

Street Address 3:   

City*:       State*:   Not Applicable Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming    Postal Code*:  

Province:     Country:     

Email Address*:  

Please re-enter your Email Address*:  

Phone Number*:   Home Work Cell

Phone Number 2 :   Home Work Cell

Best time to reach you by phone*:   

Educational Experience

Do you have a high school diploma or GED?*   Yes No

Have you ever taken any college classes?*   Yes No

Do you hold any college certificates or degrees*   Yes No

If yes, please provide dates and details:

Do you hold any professional licenses? *   Yes No

If yes, please provide dates and details:

Do you have any prior experience with kinesiology?*   Yes No

If yes, please provide dates and details:

Do you have any prior training in kinesiology*   Yes No

If yes, please provide dates and details:

Do you have any prior training in holistic health?*   Yes No

If yes, please provide dates and details:

What is your interest for taking this program?  How do you plan on using this knowledge?*