First Name: *

Last Name: *

Student G-number (if applicable):

Provide your GVSU Email Address (if applicable)
Please enter a GVSU student email address ending in @mail.gvsu.edu.

Provide your personal email address *

Cell Phone...or best number to reach you *

Date of Birth: *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Local Street Address: *

Local City: *

Local State: *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming

Local Zip Code: *

Permanent Street Address: *

Permanent City: *

Permanent State: *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming

Permanent Zip Code: *

Emergency Contact (name): *

Emergency Contact Relationship: *

Emergency Contact Street Address: *

Emergency Contact City: *

Emergency Contact State: *
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming

Emergency Contact Zip Code: *

Emergency Contact Phone (work): *

Emergency Contact Phone (home/cell): *

Current GPA: *

Please list all previous colleges and universities attended. Include ALL schools AND cumulative GPA from each school:

Are you currently taking classes at GVSU? *
- Select Option Yes No

Are you officially admitted to GVSU? *
- Select Option Yes No

If you are not currently enrolled at GVSU or are enrolled but have not yet taken GVSU classes and have not met with a College of Health Profession (CHP) academic advisor, you should:

1. Meet with a CHP academic advisor as soon as possible to review your transfer course equivalencies and program eligibility.
2. Call the CHP Student Services Office at (616) 331-5900 to set up a prospective student advising appointment.

Will you or have you completed a bachelor's degree prior to the start of the program? *
- Select Option Yes No

Please list the college/university name, major and expected degree date: *

Will you complete Anatomy & Physiology I with a "C" or better prior to the start of the program? *
- Select Option Yes No

Will you complete Anatomy & Physiology II with a "C" or better prior to the start of the program? *
- Select Option Yes No

Will you complete Medical Terminology with a "C" or better prior to the start of the program? *
- Select Option Yes No

Have you previously applied to the Health Information Management program? *
- Select Option Yes No

If Yes, what application cycle? (PLEASE NOTE: All supplemental documents will NEED to be resubmitted.) *

The following criteria must be met for your application to be complete:
Officially admitted to GVSU for the fall start of the program
All non-GVSU transcripts sent to GVSU (if taking courses elsewhere send transcripts at end of each semester)
Minimum cumulative GPA of 2.5 or higher
Grade of "C" or better in BMS 250, BMS 251 and AHS 100
Submission of this secondary application

Legal Charges and/or Convictions
Individuals who have been involved in a criminal proceeding or charged with or convicted of a crime may not be eligible for clinical placement and/or national certification and/or licensure. Students who are unable to complete a clinical placement may not be able to meet program requirements for graduation. If you have been charged or been convicted of a crime please feel free to submit this application, however we encourage you to contact the Health Information Management (HIM) Program Director, Professor Janna Pacey by email at [email protected] to inquire how this could impact your completion of the HIM program.

I have reviewed the requirements for admission into the respective program(s) and understand that the completion of this application does not guarantee that I will be accepted into the program.

Furthermore, if I am not currently enrolled at GVSU or am enrolled but have not yet taken GVSU classes and have not met with a College of Health Profession (CHP) academic advisor, I should:

1. Meet with a CHP academic advisor as soon as possible to review my transfer course equivalencies and program eligibility.
2. Call the CHP Student Services Office at (616) 331-5900 to set up a prospective student advising appointment.

Date: *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2024 2025