Current UA-PTC Student Health Information Technology Application

Current UA-PTC Student

Health Information Technology Application

First Name

Last Name

Street Address

City

State or Province

Zip/Postal Code

Country

Verify Email

Alt Email

Social Security Number (Format xxx-xx-xxxx)

Date of Birth (Month/Day/Year)

Primary Phone

Mobile Phone

Gender

When do you plan to start your journey at UA-PTC?

What student type best describes you?

Do you plan to attend classes full time or part time?

Ethnicity Information

Hispanic or Latino

Previous Enrollment History

Name of High School or GED Location?

Year of High School Graduation or GED Completion?

Highest Level of Education?

Previous College Enrollment History

Have you attended college before?

College Name: (Please make this the institution you are currently enrolled in or last attended.)

Other College previously attended:

Residency Information

Citizenship Status

Legal Arkansas Resident

YesNo

If Arkansas Residence is less than one year, provide length of residence.

Birth Country

Are you an international student on a visa?

Country of Permanent Residence

Are you, your parent, or your spouse a member or veteran of the U.S. Armed Forces?

Student Services:

University of Arkansas - Pulaski Technical College collects student information for grant programs and other student services. Please answer the questions below to help better serve our students. You may be eligible for additional programs and support based on the information shared.

Are you unemployed, underemployed, or a displaced homemaker?

Are you a single parent?

Did either of your parents earn a bachelor's (4-year) degree?

Are you homeless?

Are you in or have you aged out of foster care?

Is English your second language?

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Relationship

Emergency Contact Phone Number

By opting out of any of the forms of communication below you will not receive correspondence related to your application or acceptance status. Please note, opting out of a form of communication could delay your admissions, acceptance, or registration process as the college will have no other means to communicate this information. UA-PTC only uses your personal e-mail information for communication related your admissions or registration process.

I would like to receive text updates from the college

I would like to receive e-mail updates from the college

I would like to receive phone call updates from the college

How did you find out about us?

HIT Application Questions

Have you completed all of the HIT prerequisites?

What track do you plan to take?

I understand that all HIMT courses are taught online with the exception of the required in-person clinical rotations?

Are you able to attend clinical rotations in the Little Rock metro area?

If not, please list the area you will need to complete clinical rotations.

The Associate Degree Health Information Technology Program is in Candidacy Status, pending accreditation review by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). I have read and understand the CAHIIM accreditation status of the HIT program.

Contact Information