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PROSPECTIVE STUDENTS
 
We offer prospective students the opportunity to receive our course catalog by mail. This form also serves as a first step towards the admission process.

Please provide the following information and we will mail your packet. Keep in mind that we, at
Delaware of Health Sciences, take the privacy and security of your personal information seriously.
Feel free to review our Privacy Policy.
 
   
Name:
   
Maiden Name (if different):
   
Date of Birth:
   
Street Address:
   
City, State, Zip:
   
Email Address  (REQUIRED) :
   
Daytime Telephone:
   
Do you wish to have us call you?
Yes: No:
   
Sex:
Male: Female:
   
Employer:
Phone:
   
Employer Street Address:
   
Employer City, State, Zip:
   
EDUCATION  
   
I graduated from high school:
Yes, Year Graduated: No:
   
I have a GED:
Yes, Year GED:
   
School Name/Test Center:
   
School/Test Center City, State:
   
College (If applicable):
   
Certified Nursing Assistant or
Home Health Aid:
Yes: No:
   
Prior Health Care Experience:
(Describe)
   
Comments:
   
Delaware Institute of Health Sciences shall provide employment assistance to graduates who have met all graduation and financial requirements. There is no promise or guarantee of placement.
 
    
 
 
 
Education with emphasis on learning, community, responsibility, integrity, value, and quality nursing practice.
 
 
 
 
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